Provider Demographics
NPI:1790893329
Name:MCCABE, CONALL
Entity Type:Individual
Prefix:
First Name:CONALL
Middle Name:
Last Name:MCCABE
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 1:4910 E CLINTON WAY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93727-1560
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:
Practice Address - Street 1:290 N WAYTE LN
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93701-2124
Practice Address - Country:US
Practice Address - Phone:559-459-5700
Practice Address - Fax:559-459-4443
Is Sole Proprietor?:No
Enumeration Date:2006-08-25
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59261207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G592610Medicaid
CA00G592610Medicaid