Healthcare Provider Details

I. General information

NPI: 1508544362
Provider Name (Legal Business Name): NICHOLAS MARTIN GUPTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 05/12/2025
Certification Date: 05/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

505 PARNASSUS AVE # 624
SAN FRANCISCO CA
94143-2204
US

IV. Provider business mailing address

505 PARNASSUS AVE # 624
SAN FRANCISCO CA
94143-2204
US

V. Phone/Fax

Practice location:
  • Phone: 415-353-1116
  • Fax:
Mailing address:
  • Phone: 415-353-1116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN264547
License Number StateGA
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberNP95033221
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: