Healthcare Provider Details

I. General information

NPI: 1801919253
Provider Name (Legal Business Name): NICHOLAS BURLEY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/09/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

136 N SAN MATEO DR SUITE 101
SAN MATEO CA
94401-2777
US

IV. Provider business mailing address

2750 GEORGETOWN ST
EAST PALO ALTO CA
94303-1213
US

V. Phone/Fax

Practice location:
  • Phone: 650-578-8691
  • Fax: 650-578-8697
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: