Provider Demographics
NPI:1013620939
Name:DAS, PRIYANKA
Entity Type:Individual
Prefix:
First Name:PRIYANKA
Middle Name:
Last Name:DAS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4704 BRANDING IRON DR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-7468
Mailing Address - Country:US
Mailing Address - Phone:714-930-3296
Mailing Address - Fax:
Practice Address - Street 1:4704 BRANDING IRON DR
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-7468
Practice Address - Country:US
Practice Address - Phone:714-930-3296
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-05
Last Update Date:2023-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95024376163WG0000X
CA95190498163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral PracticeGroup - Multi-Specialty