Basic Information
| Provider Information | |||||||||
| NPI: | 1992022826 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | KAISER PERMANENTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9961 SIERRA AVE | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923356720 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9961 SIERRA AVE | ||||||||
| Address2: | |||||||||
| City: | FONTANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923356720 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9094275083 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2010 | ||||||||
| LastUpdateDate: | 04/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | TRANTHAM | ||||||||
| AuthorizedOfficialFirstName: | PATRICIA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | RESIDENCY DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 9094275083 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 04/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | A111397 | CA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.