Healthcare Provider Details

I. General information

NPI: 1780283143
Provider Name (Legal Business Name): IGOR GRUNA MOCORRO DNP, MPH, FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/17/2020
Last Update Date: 10/17/2020
Certification Date: 10/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

375 LAGUNA HONDA BLVD
SAN FRANCISCO CA
94116-1499
US

IV. Provider business mailing address

126 DOLPHIN CT
SAN FRANCISCO CA
94124-2945
US

V. Phone/Fax

Practice location:
  • Phone: 415-699-2402
  • Fax: 415-682-5668
Mailing address:
  • Phone: 415-818-5654
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number765153
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95015593
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: