Provider Demographics
NPI:1336709419
Name:PALAC, JOHN PAUL CANUDAY
Entity Type:Individual
Prefix:
First Name:JOHN PAUL
Middle Name:CANUDAY
Last Name:PALAC
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 1:3715 W BARSTOW AVE APT 233
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93711-6666
Mailing Address - Country:US
Mailing Address - Phone:831-539-6683
Mailing Address - Fax:
Practice Address - Street 1:3451 W SHAW AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3242
Practice Address - Country:US
Practice Address - Phone:831-539-6683
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-19
Last Update Date:2020-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical