=====================================================
General NPI Number Information
=====================================================
NPI Number | 1801361993
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERICA TRISTAN NEUBERT NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/04/2018
-----------------------------------------------------
Last Update Date | 04/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9834 GENESEE AVE STE 300
-----------------------------------------------------
City | LA JOLLA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92037-1215
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 858-824-2900
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4022 LAMONT ST APT 1
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92109-6285
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-787-1346
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 95010118
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------