Provider Demographics
NPI:1245739283
Name:HERZOG, GEORGE HOWARD (RN, CNS)
Entity Type:Individual
Prefix:
First Name:GEORGE
Middle Name:HOWARD
Last Name:HERZOG
Suffix:
Gender:M
Credentials:RN, CNS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88 PALISADES DR
Mailing Address - Street 2:
Mailing Address - City:DALY CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94015-4511
Mailing Address - Country:US
Mailing Address - Phone:415-516-9852
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST G1-111B1
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121
Practice Address - Country:US
Practice Address - Phone:415-221-4810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-05
Last Update Date:2018-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4606364SG0600X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA2016008577OtherANCC ADULT-GERONTOLOGY CNS CERTIFICATION
CA493597OtherCALIFORNIA BOARD OF REGISTERED NURSING REGISTERED NURSE
CA4606OtherCALIFORNIA BOARD OF REGISTERED NURSING CLINICAL NURSE SPECIALIST