Healthcare Provider Details

I. General information

NPI: 1003633454
Provider Name (Legal Business Name): WILLIAM RUSSEL CARPENTER FNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

1001 POTRERO AVE
SAN FRANCISCO CA
94110-3594
US

IV. Provider business mailing address

723 44TH AVE
SAN FRANCISCO CA
94121-3305
US

V. Phone/Fax

Practice location:
  • Phone: 628-206-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022651
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: