Provider Demographics
NPI:1902877236
Name:PRENTICE, ANNE MARIE (MD)
Entity type:Individual
Prefix:
First Name:ANNE
Middle Name:MARIE
Last Name:PRENTICE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2625 E DIVISADERO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93721-1431
Mailing Address - Country:US
Mailing Address - Phone:559-443-2682
Mailing Address - Fax:
Practice Address - Street 1:1247 E ALLUVIAL AVE STE 101
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-2686
Practice Address - Country:US
Practice Address - Phone:559-431-6226
Practice Address - Fax:559-440-9005
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60257174400000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020045926OtherRAILROAD MEDICARE
CA00A602570OtherMEDI-CAL
CAH15342Medicare UPIN
CACG818ZMedicare PIN
CACG818ZMedicare PIN