Provider Demographics
NPI:1407228208
Name:RISENHOOVER, DALE THOMAS (PA-C)
Entity Type:Individual
Prefix:
First Name:DALE
Middle Name:THOMAS
Last Name:RISENHOOVER
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 21ST ST
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95811-5216
Mailing Address - Country:US
Mailing Address - Phone:916-443-3299
Mailing Address - Fax:
Practice Address - Street 1:1500 21ST ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95811-5216
Practice Address - Country:US
Practice Address - Phone:916-443-3299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-20
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA52935363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical