Provider Demographics
NPI:1316391642
Name:DEPAOLI, JOEL R (PA)
Entity Type:Individual
Prefix:MR
First Name:JOEL
Middle Name:R
Last Name:DEPAOLI
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 1:1060 CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:ALAMEDA
Mailing Address - State:CA
Mailing Address - Zip Code:94501-2365
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2395 LOMBARD ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94123
Practice Address - Country:US
Practice Address - Phone:415-796-2242
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-23
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53353363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA197976Medicare PIN