Healthcare Provider Details

I. General information

NPI: 1508156910
Provider Name (Legal Business Name): NATHAN DARIO BRINCKHAUS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2011
Last Update Date: 12/19/2024
Certification Date: 12/19/2024
Deactivation Date: 12/09/2024
Reactivation Date: 12/17/2024

III. Provider practice location address

2404 NEWBURG RD
FORTUNA CA
95540-2818
US

IV. Provider business mailing address

2404 NEWBURG RD
FORTUNA CA
95540-2818
US

V. Phone/Fax

Practice location:
  • Phone: 707-617-2002
  • Fax: 833-941-4882
Mailing address:
  • Phone: 707-617-2002
  • Fax: 833-941-4882

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberA124994
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: