Provider Demographics
NPI:1700936309
Name:UCD-SOM NEUROLOGICAL SURGERY
Entity Type:Organization
Organization Name:UCD-SOM NEUROLOGICAL SURGERY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:BRIDGET
Authorized Official - Middle Name:M
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RN, NP
Authorized Official - Phone:916-734-3658
Mailing Address - Street 1:4860 Y ST STE 3740
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2307
Mailing Address - Country:US
Mailing Address - Phone:916-734-3658
Mailing Address - Fax:916-703-5368
Practice Address - Street 1:2315 STOCKTON BOULEVARD, SUITE 3740 ACC
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2201
Practice Address - Country:US
Practice Address - Phone:916-734-3658
Practice Address - Fax:916-703-5368
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11306275N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes275N00000XHospital UnitsMedicare Defined Swing Bed Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA007594Medicare UPIN