Healthcare Provider Details

I. General information

NPI: 1578368015
Provider Name (Legal Business Name): RYAN GOURLEY RN FA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/18/2025
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3450 SACRAMENTO ST # 130
SAN FRANCISCO CA
94118-2712
US

IV. Provider business mailing address

3450 SACRAMENTO ST # 130
SAN FRANCISCO CA
94118-2712
US

V. Phone/Fax

Practice location:
  • Phone: 415-418-9433
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0121X
TaxonomyPlastic Surgery Registered Nurse
License Number95133240
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: