MEDICARE: DAVID PHAK PMHNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	95066269	CA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	95029043	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0000	OTHER		N/A

General Provider Information

NPI Number	:	1366169849
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DAVID PHAK PMHNP-BC

Provider Business Mailing Address
First Line	:	191 S BUENA VISTA ST STE 300
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4556
Country	:	US
Telephone Number	:	925-282-1778
Fax Number	:

Provider Business Practice Location Address
First Line	:	191 S BUENA VISTA ST STE 300
Second Line	:
City	:	BURBANK
State	:	CA
Zip	:	91505-4556
Country	:	US
Telephone Number	:	925-282-1778
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/25/2022
Last Update Date	:	01/20/2026

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