Healthcare Provider Details

I. General information

NPI: 1003143223
Provider Name (Legal Business Name): GREGORY SUMNER PAYNE BRYNELSON RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GREG PAYNE BRYNELSON RN

II. Dates (important events)

Enumeration Date: 11/09/2009
Last Update Date: 11/09/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 MISSION ROCK ST UNIT 103
SAN FRANCISCO CA
94158-2150
US

IV. Provider business mailing address

555 MISSION ROCK ST UNIT 103
SAN FRANCISCO CA
94158-2150
US

V. Phone/Fax

Practice location:
  • Phone: 415-513-2902
  • Fax:
Mailing address:
  • Phone: 415-513-2902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WM0705X
TaxonomyMedical-Surgical Registered Nurse
License Number689286
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: