=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437213717
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NAVAL MEDICAL CENTER SAN DIEGO
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2006
-----------------------------------------------------
Last Update Date | 08/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 34800 BOB WILSON DR
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92134-1098
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-532-6886
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2148 ESTELA DR
-----------------------------------------------------
City | EL CAJON
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92020-1010
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PEDIATRIC NURSE PRACTITIONER
-----------------------------------------------------
Name | MARY PATRICIA WHITE
-----------------------------------------------------
Credential | CPNP
-----------------------------------------------------
Telephone | 619-532-6886
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 286500000X
-----------------------------------------------------
Taxonomy Name | Military Hospital
-----------------------------------------------------
License Number | L1-0029636
-----------------------------------------------------
License Number State | DE
-----------------------------------------------------