Provider Demographics
NPI:1093056525
Name:CEBALLOS, MARTIN (PA)
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:
Last Name:CEBALLOS
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 1:7004 DANBERG WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95757-4006
Mailing Address - Country:US
Mailing Address - Phone:209-468-6000
Mailing Address - Fax:209-468-7042
Practice Address - Street 1:500 W HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:FRENCH CAMP
Practice Address - State:CA
Practice Address - Zip Code:95231-9693
Practice Address - Country:US
Practice Address - Phone:209-468-6000
Practice Address - Fax:209-468-7042
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22222363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant