Healthcare Provider Details

I. General information

NPI: 1710559588
Provider Name (Legal Business Name): NOAH ISAAC STASHOWER-MARCUS NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2021
Last Update Date: 10/17/2024
Certification Date: 10/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5060 SHOREHAM PL STE 230&330
SAN DIEGO CA
92122-5903
US

IV. Provider business mailing address

5060 SHOREHAM PL STE 230&330
SAN DIEGO CA
92122-5903
US

V. Phone/Fax

Practice location:
  • Phone: 858-999-1897
  • Fax:
Mailing address:
  • Phone: 858-999-1897
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95032614
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: