Healthcare Provider Details

I. General information

NPI: 1932925831
Provider Name (Legal Business Name): NICHOLAS MICHAEL COOPER RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/25/2024
Last Update Date: 09/03/2026
Certification Date: 09/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4309 3RD AVE
SAN DIEGO CA
92103-1407
US

IV. Provider business mailing address

6490 AMBROSIA DR APT 5108
SAN DIEGO CA
92124-5107
US

V. Phone/Fax

Practice location:
  • Phone: 619-876-4502
  • Fax:
Mailing address:
  • Phone: 407-406-7071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95041195
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95360729
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: