MEDICARE: GRANT NYBAKKEN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207ZP0105X	Clinical Pathology/Laboratory Medicine Physician	MT193042	PA

General Provider Information

NPI Number	:	1104088400
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GRANT NYBAKKEN M.D.

Provider Business Mailing Address
First Line	:	383 E GRAND AVE STE A
Second Line	:
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-6234
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	383 E GRAND AVE STE A
Second Line	:
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-6234
Country	:	US
Telephone Number	:	650-616-2951
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/27/2008
Last Update Date	:	11/22/2024

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