=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275736621
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARSHALL LEWIS BLOUNT V FNP PRACTITONER
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/05/2007
-----------------------------------------------------
Last Update Date | 06/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2238 GEARY BLVD
-----------------------------------------------------
City | SAN FRANCISCO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94115-3416
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-833-2000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2261 VALENTANO DR
-----------------------------------------------------
City | DUBLIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94568-3312
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-230-1348
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | NP95030340
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------