Healthcare Provider Details

I. General information

NPI: 1588470645
Provider Name (Legal Business Name): AMU XENAPHON DARYA AGPCNP, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6 TARMAN DR
CLOVERDALE CA
95425-3932
US

IV. Provider business mailing address

6 TARMAN DR
CLOVERDALE CA
95425-3932
US

V. Phone/Fax

Practice location:
  • Phone: 707-894-4229
  • Fax:
Mailing address:
  • Phone: 213-248-1556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SA2100X
TaxonomyAcute Care Clinical Nurse Specialist
License Number12345
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95035288
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: