Provider Demographics
NPI:1023044427
Name:TJERANDSEN, CARL E (PA)
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:E
Last Name:TJERANDSEN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:STE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1844
Mailing Address - Country:US
Mailing Address - Phone:510-851-7423
Mailing Address - Fax:510-879-9120
Practice Address - Street 1:2175 ROSALINE AVE
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96001-2509
Practice Address - Country:US
Practice Address - Phone:530-225-6000
Practice Address - Fax:818-587-2493
Is Sole Proprietor?:No
Enumeration Date:2006-06-25
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18091363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18091Medicaid
CAP00291750OtherRAILROAD MEDICARE
CAP00291750OtherRAILROAD MEDICARE
CAQ65591Medicare UPIN