Provider Demographics
NPI:1952492936
Name:THERIAULT, JULIE A (PA)
Entity Type:Individual
Prefix:
First Name:JULIE
Middle Name:A
Last Name:THERIAULT
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:800-470-0071
Mailing Address - Fax:
Practice Address - Street 1:8170 LAGUNA BLVD
Practice Address - Street 2:#215
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-7901
Practice Address - Country:US
Practice Address - Phone:916-691-5900
Practice Address - Fax:916-691-6747
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2015-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12102363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0PA121020Medicaid
CA0PA121020Medicaid
0PA121020Medicare ID - Type Unspecified
CA0PA121022Medicare PIN