Healthcare Provider Details

I. General information

NPI: 1790905156
Provider Name (Legal Business Name): UCSF MEDICAL CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2007
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

SAN QUENTIN STATE PRISON
SAN QUENTIN CA
94964
US

IV. Provider business mailing address

1689 19TH AVE
SAN FRANCISCO CA
94122-4517
US

V. Phone/Fax

Practice location:
  • Phone: 415-454-1460
  • Fax:
Mailing address:
  • Phone: 415-420-7572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP12252
License Number StateCA

VIII. Authorized Official

Name: TEH L LEE
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 415-420-7572