Healthcare Provider Details

I. General information

NPI: 1912464074
Provider Name (Legal Business Name): MARC JEREMY CRUZ ACNPC-AG CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/25/2019
Last Update Date: 10/29/2021
Certification Date: 10/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 OLD RIVER RD STE 200
BAKERSFIELD CA
93311-9505
US

IV. Provider business mailing address

1414 E MAIN ST STE 201
SANTA MARIA CA
93454-4890
US

V. Phone/Fax

Practice location:
  • Phone: 661-663-6429
  • Fax: 661-663-6041
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95012206
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number674363
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: