Provider Demographics
NPI:1255434452
Name:PRAVER, SUSANA JUDITH (PAC)
Entity type:Individual
Prefix:
First Name:SUSANA
Middle Name:JUDITH
Last Name:PRAVER
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:SHOSHANA
Other - Middle Name:JUDITH
Other - Last Name:PRAVER
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1601 FRUITVALE AVE
Mailing Address - Street 2:
Mailing Address - City:OAKLAND
Mailing Address - State:CA
Mailing Address - Zip Code:94601-2322
Mailing Address - Country:US
Mailing Address - Phone:510-535-4000
Mailing Address - Fax:510-535-4128
Practice Address - Street 1:3451 E 12TH ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94601
Practice Address - Country:US
Practice Address - Phone:510-535-3317
Practice Address - Fax:510-535-4248
Is Sole Proprietor?:No
Enumeration Date:2006-09-06
Last Update Date:2010-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10842363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAHAP72021FOtherFPACT
CAFHC71021FMedicaid
CA55-1975OtherFQHC MEDICARE PART A
CAZZZ29799ZOtherFQHC MEDICARE PART B