Provider Demographics
NPI:1427681535
Name:HUMPHREY, ANNIE (PA-C)
Entity type:Individual
Prefix:
First Name:ANNIE
Middle Name:
Last Name:HUMPHREY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ANNIE
Other - Middle Name:
Other - Last Name:HUMPHREY
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4165 BLACKHAWK PLAZA CIR
Mailing Address - Street 2:STE 100
Mailing Address - City:DANVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94506-4691
Mailing Address - Country:US
Mailing Address - Phone:925-736-7070
Mailing Address - Fax:925-736-7075
Practice Address - Street 1:4165 BLACKHAWK PLAZA CIR
Practice Address - Street 2:STE 100
Practice Address - City:DANVILLE
Practice Address - State:CA
Practice Address - Zip Code:94506-4691
Practice Address - Country:US
Practice Address - Phone:925-736-7070
Practice Address - Fax:925-736-7075
Is Sole Proprietor?:No
Enumeration Date:2020-02-17
Last Update Date:2025-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA58037363AM0700X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical