Healthcare Provider Details

I. General information

NPI: 1336303577
Provider Name (Legal Business Name): WAYNE DAVID OVERLY CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2008
Last Update Date: 07/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VA SAN DIEGO HEALTHCARE SYSTEM 3350 LA JOLLA VILLAGE DRIVE
SAN DIEGO CA
92161-0001
US

IV. Provider business mailing address

10406 WILD ORCHID WAY
SAN DIEGO CA
92127-2876
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-8585
  • Fax:
Mailing address:
  • Phone: 858-254-0568
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License Number501535
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: