Provider Demographics
NPI:1659774602
Name:PERALTA, ECSTACY
Entity Type:Individual
Prefix:
First Name:ECSTACY
Middle Name:
Last Name:PERALTA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:321 W CHENNAULT AVE
Mailing Address - Street 2:APT 225
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93611-0217
Mailing Address - Country:US
Mailing Address - Phone:408-420-4628
Mailing Address - Fax:
Practice Address - Street 1:468 N VERMONT AVE
Practice Address - Street 2:
Practice Address - City:DINUBA
Practice Address - State:CA
Practice Address - Zip Code:93618-1631
Practice Address - Country:US
Practice Address - Phone:559-591-6200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-10-06
Last Update Date:2021-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA51945363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant