Provider Demographics
NPI:1700293339
Name:BERTOLI, MARA (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:MARA
Middle Name:
Last Name:BERTOLI
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:MISS
Other - First Name:MARA
Other - Middle Name:
Other - Last Name:BOOSTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP-C
Mailing Address - Street 1:1255 N DUTTON AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95401-4663
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1255 N DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95401-4663
Practice Address - Country:US
Practice Address - Phone:707-546-9400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-15
Last Update Date:2015-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000942363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACA151349OtherMEDICARE ID