Provider Demographics
NPI:1275146870
Name:SALAS, MARY KATHARINE (CNS)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:KATHARINE
Last Name:SALAS
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:524 COCONUT PL
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-1994
Mailing Address - Country:US
Mailing Address - Phone:925-642-1260
Mailing Address - Fax:
Practice Address - Street 1:4501 SAND CREEK RD
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-8687
Practice Address - Country:US
Practice Address - Phone:925-813-6534
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-25
Last Update Date:2021-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4872364SG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4872OtherCALIFORNIA BRN