Provider Demographics
NPI:1356631840
Name:LUPORINI, AMELIE (PA, RD)
Entity Type:Individual
Prefix:
First Name:AMELIE
Middle Name:
Last Name:LUPORINI
Suffix:
Gender:F
Credentials:PA, RD
Other - Prefix:
Other - First Name:AMELIE
Other - Middle Name:
Other - Last Name:BERNARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA, RD
Mailing Address - Street 1:2350 W EL CAMINO REAL FL 2
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:CA
Mailing Address - Zip Code:94040-6203
Mailing Address - Country:US
Mailing Address - Phone:707-541-7900
Mailing Address - Fax:707-573-5411
Practice Address - Street 1:34 MARK WEST SPRINGS RD FL 2
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403
Practice Address - Country:US
Practice Address - Phone:707-541-7900
Practice Address - Fax:707-573-5411
Is Sole Proprietor?:No
Enumeration Date:2011-04-18
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56379363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA56379OtherSTATE MEDICAL LICENSE
CAMB5161233OtherFEDERAL DEA LICENSE