Healthcare Provider Details

I. General information

NPI: 1275050437
Provider Name (Legal Business Name): GREGORY CHRISTOPHER STAVARIDIS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2017
Last Update Date: 08/28/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 E DEL MAR BLVD
PASADENA CA
91107-4375
US

IV. Provider business mailing address

680 HARBOR ST APT 1
VENICE CA
90291-4783
US

V. Phone/Fax

Practice location:
  • Phone: 626-795-9901
  • Fax:
Mailing address:
  • Phone: 303-232-0296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95006943
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: