Provider Demographics
NPI:1780646505
Name:SENTER, PHYLLIS JACQUELINE (MD)
Entity Type:Individual
Prefix:DR
First Name:PHYLLIS
Middle Name:JACQUELINE
Last Name:SENTER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3883 AIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-1670
Mailing Address - Country:US
Mailing Address - Phone:707-571-7777
Mailing Address - Fax:707-573-1308
Practice Address - Street 1:3883 AIRWAY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403
Practice Address - Country:US
Practice Address - Phone:707-571-7777
Practice Address - Fax:707-523-1308
Is Sole Proprietor?:No
Enumeration Date:2006-04-05
Last Update Date:2012-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG34906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G349060Medicaid
CA00G349060Medicaid
CA00G349060Medicare ID - Type Unspecified