Healthcare Provider Details

I. General information

NPI: 1588470645
Provider Name (Legal Business Name): AMU XENAPHON DARYA AGPCNP, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/04/2024
Last Update Date: 12/04/2024
Certification Date: 12/04/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12400 HIGH BLUFF DR
SAN DIEGO CA
92130-3077
US

IV. Provider business mailing address

PO BOX 5080
SAN DIEGO CA
92165-5080
US

V. Phone/Fax

Practice location:
  • Phone: 213-248-1556
  • Fax:
Mailing address:
  • Phone: 213-248-1556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SC0200X
TaxonomyCritical Care Medicine Clinical Nurse Specialist
License Number11111111111
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number111111111111111
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: