Provider Demographics
NPI:1689299216
Name:ILDEFONSO SALAS, MARIA NATHALI
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:NATHALI
Last Name:ILDEFONSO SALAS
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 1:423 SAN ANSELMO AVE N
Mailing Address - Street 2:
Mailing Address - City:SAN BRUNO
Mailing Address - State:CA
Mailing Address - Zip Code:94066-4436
Mailing Address - Country:US
Mailing Address - Phone:650-580-3610
Mailing Address - Fax:
Practice Address - Street 1:170 S SPRUCE AVE STE 200
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-4557
Practice Address - Country:US
Practice Address - Phone:650-517-8220
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-09
Last Update Date:2020-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker