Healthcare Provider Details

I. General information

NPI: 1720630197
Provider Name (Legal Business Name): JAMES DEAN STALIANS AGNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JIM STALIANS AGNP

II. Dates (important events)

Enumeration Date: 07/15/2019
Last Update Date: 07/15/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1540 FLORIDA AVE
MODESTO CA
95350-4430
US

IV. Provider business mailing address

737 W CHILDS AVE
MERCED CA
95341-6805
US

V. Phone/Fax

Practice location:
  • Phone: 866-682-4842
  • Fax:
Mailing address:
  • Phone: 866-682-4842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0600X
TaxonomyGerontology Registered Nurse
License Number452145
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95010123
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95010123
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: