Provider Demographics
NPI:1700236916
Name:KONAN, MAXIME
Entity Type:Individual
Prefix:
First Name:MAXIME
Middle Name:
Last Name:KONAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1350 HAYES ST STE C4
Mailing Address - Street 2:
Mailing Address - City:BENICIA
Mailing Address - State:CA
Mailing Address - Zip Code:94510-2969
Mailing Address - Country:US
Mailing Address - Phone:510-692-1804
Mailing Address - Fax:
Practice Address - Street 1:1350 HAYES ST STE C4
Practice Address - Street 2:
Practice Address - City:BENICIA
Practice Address - State:CA
Practice Address - Zip Code:94510-2969
Practice Address - Country:US
Practice Address - Phone:510-692-1804
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-18
Last Update Date:2016-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA35945OtherPUBLIC UTILITIES COMMISSION OF THE STATE OF CALIFORNIA