Provider Demographics
NPI:1225473242
Name:ATAIE EBUEN, MARINA (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARINA
Middle Name:
Last Name:ATAIE EBUEN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 FLAGSHIP DR
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94592-1178
Mailing Address - Country:US
Mailing Address - Phone:415-860-4915
Mailing Address - Fax:
Practice Address - Street 1:3100 TELEGRAPH AVE
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3239
Practice Address - Country:US
Practice Address - Phone:510-869-6629
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-03
Last Update Date:2013-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19663363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily