Provider Demographics
NPI:1821002593
Name:MAZZETTI HISEROTE, PATRICIA ANNE (DO)
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANNE
Last Name:MAZZETTI HISEROTE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:PATRICIA
Other - Middle Name:ANNE
Other - Last Name:MAZZETTI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:401 BICENTENNIAL WAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95403-2149
Mailing Address - Country:US
Mailing Address - Phone:707-393-5412
Mailing Address - Fax:
Practice Address - Street 1:401 BICENTENNIAL WAY
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95403-2149
Practice Address - Country:US
Practice Address - Phone:707-571-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8380207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI23890Medicare UPIN