Provider Demographics
NPI:1417205527
Name:NAKKERUD-WHITESIDE, BRIAN JAMES (RN, PMHFNPC)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:JAMES
Last Name:NAKKERUD-WHITESIDE
Suffix:
Gender:M
Credentials:RN, PMHFNPC
Other - Prefix:MR
Other - First Name:BRIAN
Other - Middle Name:JAMES
Other - Last Name:NAKKERUD-WHITESIDE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN, PMHFNPC
Mailing Address - Street 1:1400 EMELINE AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95060-1976
Mailing Address - Country:US
Mailing Address - Phone:831-454-4170
Mailing Address - Fax:831-454-4663
Practice Address - Street 1:1400 EMELINE AVE
Practice Address - Street 2:
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95060-1976
Practice Address - Country:US
Practice Address - Phone:831-454-4170
Practice Address - Fax:831-454-4663
Is Sole Proprietor?:No
Enumeration Date:2012-08-21
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA802020163W00000X
CA87055363LP0808X
CA23511363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91891ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAFHC70042FOtherMEDI-CAL PTAN GROUP#
CAZZZ92069ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#
CAFHC70044FOtherMEDI-CAL PTAN GROUP#
CAZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#