Healthcare Provider Details

I. General information

NPI: 1356141758
Provider Name (Legal Business Name): DOUGLAS ANDERSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/14/2025
Last Update Date: 03/14/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

601 BAYONET CIR
MARINA CA
93933-4600
US

IV. Provider business mailing address

PO BOX 222021
CARMEL CA
93922-2021
US

V. Phone/Fax

Practice location:
  • Phone: 831-647-3000
  • Fax:
Mailing address:
  • Phone: 831-238-3660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number287544
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: