Provider Demographics
NPI:1699841155
Name:BRUKETTA, PATRICIA (NP)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:
Last Name:BRUKETTA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3553 WHIPPLE RD
Mailing Address - Street 2:BUILDING B, MED 1
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-1507
Mailing Address - Country:US
Mailing Address - Phone:510-675-4880
Mailing Address - Fax:
Practice Address - Street 1:3553 WHIPPLE RD
Practice Address - Street 2:BUILDING B, MED 1
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1507
Practice Address - Country:US
Practice Address - Phone:510-675-4880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA408641363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAP18204Medicare UPIN