Healthcare Provider Details

I. General information

NPI: 1780300814
Provider Name (Legal Business Name): JOHN PATRICK MCNULTY MS, CCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2022
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 PASTEUR DR
PALO ALTO CA
94304-1048
US

IV. Provider business mailing address

500 PASTEUR DR
PALO ALTO CA
94304-1048
US

V. Phone/Fax

Practice location:
  • Phone: 650-353-1656
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number189074
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: