Healthcare Provider Details

I. General information

NPI: 1134179302
Provider Name (Legal Business Name): JOHN A. KERMEN, D.O.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/11/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 RIVER DR
FORT BRAGG CA
95437-5403
US

IV. Provider business mailing address

PO BOX 34120
RENO NV
89533-4120
US

V. Phone/Fax

Practice location:
  • Phone: 707-961-1234
  • Fax:
Mailing address:
  • Phone: 775-747-5050
  • Fax: 775-747-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number StateCA

VIII. Authorized Official

Name: JOHN A KERMEN
Title or Position: PRESIDENT
Credential: D.O.
Phone: 707-961-1234