Healthcare Provider Details

I. General information

NPI: 1548388861
Provider Name (Legal Business Name): MARK LEWIS ILLEMAN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2007
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 CALIFORNIA ST SUITE 306
SAN FRANCISCO CA
94115-2753
US

IV. Provider business mailing address

2300 CALIFORNIA ST SUITE 306
SAN FRANCISCO CA
94115-2753
US

V. Phone/Fax

Practice location:
  • Phone: 415-202-1550
  • Fax: 415-776-8233
Mailing address:
  • Phone: 415-202-1550
  • Fax: 415-776-8233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2005
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: