MEDICARE: MIRTA M CUEVAS RN, PHN

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	163WC1500X	Community Health Registered Nurse	467948	CA

General Provider Information

NPI Number	:	1902045701
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIRTA M CUEVAS RN, PHN

Provider Business Mailing Address
First Line	:	899 NORTHGATE DR STE 100
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94903-3664
Country	:	US
Telephone Number	:	415-473-2623
Fax Number	:

Provider Business Practice Location Address
First Line	:	899 NORTHGATE DR STE 100
Second Line	:
City	:	SAN RAFAEL
State	:	CA
Zip	:	94903-3664
Country	:	US
Telephone Number	:	415-473-2623
Fax Number	:

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

Provider Enumeration Date	:	02/18/2009
Last Update Date	:	02/18/2009

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