Healthcare Provider Details

I. General information

NPI: 1134277254
Provider Name (Legal Business Name): GARY KEITH HERMANSEN NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2007
Last Update Date: 07/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 DONAHUE ST
SAUSALITO CA
94965-1032
US

IV. Provider business mailing address

308 DONAHUE ST
SAUSALITO CA
94965-1032
US

V. Phone/Fax

Practice location:
  • Phone: 415-535-3659
  • Fax:
Mailing address:
  • Phone: 415-535-3659
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number7066932-8900
License Number StateUT
# 2
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number1008
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: