Provider Demographics
NPI:1295210995
Name:VASSALO, BRIAN CHRISTOPHER
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:CHRISTOPHER
Last Name:VASSALO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1528 WOOLSEY ST APT D
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94703-2353
Mailing Address - Country:US
Mailing Address - Phone:510-999-2728
Mailing Address - Fax:
Practice Address - Street 1:1528 WOOLSEY ST APT D
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94703-2353
Practice Address - Country:US
Practice Address - Phone:510-999-2728
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-27
Last Update Date:2018-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010119363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily