Healthcare Provider Details

I. General information

NPI: 1134735533
Provider Name (Legal Business Name): VICENTE FERNANDO GATAN III NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/21/2020
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10042 MERRY BROOK TRL
SANTEE CA
92071-7211
US

IV. Provider business mailing address

10042 MERRY BROOK TRL
SANTEE CA
92071-7211
US

V. Phone/Fax

Practice location:
  • Phone: 619-517-6205
  • Fax:
Mailing address:
  • Phone: 619-517-6205
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95014825
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: