Healthcare Provider Details

I. General information

NPI: 1104088400
Provider Name (Legal Business Name): GRANT NYBAKKEN M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2008
Last Update Date: 11/22/2024
Certification Date: 11/22/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

383 E GRAND AVE STE A
SOUTH SAN FRANCISCO CA
94080-6234
US

IV. Provider business mailing address

383 E GRAND AVE STE A
SOUTH SAN FRANCISCO CA
94080-6234
US

V. Phone/Fax

Practice location:
  • Phone: 650-616-2951
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License NumberMT193042
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: