Provider Demographics
NPI:1578525598
Name:FARE, WISAL (PA-C)
Entity Type:Individual
Prefix:
First Name:WISAL
Middle Name:
Last Name:FARE
Suffix:
Gender:F
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 1:4721 DALLAS RANCH RD
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8811
Mailing Address - Country:US
Mailing Address - Phone:925-778-0679
Mailing Address - Fax:925-778-3567
Practice Address - Street 1:13851 E 14TH ST
Practice Address - Street 2:STE 305
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94578-2631
Practice Address - Country:US
Practice Address - Phone:510-351-1193
Practice Address - Fax:510-351-6456
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2014-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13725364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110006522OtherPTAN
CAZZZ15328ZOtherPTAN
CA0PA137250Medicare ID - Type Unspecified