Provider Demographics
NPI:1083857361
Name:RAMEN, GAJENDRAN (MS HUMAN NUTRITION)
Entity Type:Individual
Prefix:
First Name:GAJENDRAN
Middle Name:
Last Name:RAMEN
Suffix:
Gender:M
Credentials:MS HUMAN NUTRITION
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 LEISURE PARK CIR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-5882
Mailing Address - Country:US
Mailing Address - Phone:707-889-0918
Mailing Address - Fax:
Practice Address - Street 1:35 LEISURE PARK CIR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-5882
Practice Address - Country:US
Practice Address - Phone:707-889-0918
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-04-15
Last Update Date:2016-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133NN1002X, 335G00000X
CA1055199133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No335G00000XSuppliersMedical Foods Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA227859Medicare PIN