Healthcare Provider Details

I. General information

NPI: 1609473735
Provider Name (Legal Business Name): ETHAN HUFFMAN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2020
Last Update Date: 06/22/2022
Certification Date: 06/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

245 11TH ST
SAN FRANCISCO CA
94103-3732
US

IV. Provider business mailing address

245 11TH ST
SAN FRANCISCO CA
94103-3732
US

V. Phone/Fax

Practice location:
  • Phone: 415-431-9000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95015491
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: