Provider Demographics
NPI:1972780997
Name:EBOH, DARLA JEAN (ANP)
Entity type:Individual
Prefix:MS
First Name:DARLA
Middle Name:JEAN
Last Name:EBOH
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:945 CRESTA WAY
Mailing Address - Street 2:APT 5
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94903-5585
Mailing Address - Country:US
Mailing Address - Phone:415-419-7136
Mailing Address - Fax:
Practice Address - Street 1:2600 MACDONALD AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94804-1826
Practice Address - Country:US
Practice Address - Phone:415-233-2849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-22
Last Update Date:2011-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY304313363L00000X
CA204110363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner