Provider Demographics
NPI:1356448237
Name:SKATES, SANDRA BETH (D,O)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:BETH
Last Name:SKATES
Suffix:
Gender:F
Credentials:D,O
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:421 NUT TREE RD
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-3508
Mailing Address - Country:US
Mailing Address - Phone:707-624-7580
Mailing Address - Fax:707-624-7501
Practice Address - Street 1:421 NUT TREE RD
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-3508
Practice Address - Country:US
Practice Address - Phone:707-624-7580
Practice Address - Fax:707-624-7501
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-20
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A5614204D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE78625Medicare UPIN