Provider Demographics
NPI:1376877134
Name:DURIVAGE, NICOLAS JULIEN
Entity Type:Individual
Prefix:
First Name:NICOLAS
Middle Name:JULIEN
Last Name:DURIVAGE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1416 GRANT AVE
Mailing Address - Street 2:APT 21
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94133-3355
Mailing Address - Country:US
Mailing Address - Phone:763-439-1092
Mailing Address - Fax:
Practice Address - Street 1:1701 OCEAN AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94112-1727
Practice Address - Country:US
Practice Address - Phone:415-452-2200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-09-28
Last Update Date:2009-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program