Provider Demographics
NPI:1205813771
Name:NYQUIST, JULIA (MD)
Entity Type:Individual
Prefix:
First Name:JULIA
Middle Name:
Last Name:NYQUIST
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 SANTA CLARA AVE
Mailing Address - Street 2:REAR COTTAGE
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-3225
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:311 SANTA CLARA AVE
Practice Address - Street 2:REAR COTTAGE
Practice Address - City:ALAMEDA
Practice Address - State:CA
Practice Address - Zip Code:94501-3225
Practice Address - Country:US
Practice Address - Phone:141-561-3507
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-27
Last Update Date:2011-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG79638208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
F93598Medicare UPIN