Provider Demographics
NPI:1427045848
Name:GRUIDL, MARK RICHARD (NP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:RICHARD
Last Name:GRUIDL
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2677
Mailing Address - Street 2:
Mailing Address - City:ATASCADERO
Mailing Address - State:CA
Mailing Address - Zip Code:93423-2677
Mailing Address - Country:US
Mailing Address - Phone:805-748-8897
Mailing Address - Fax:805-434-0308
Practice Address - Street 1:1020 FAVA CT
Practice Address - Street 2:
Practice Address - City:TEMPLETON
Practice Address - State:CA
Practice Address - Zip Code:93465-3826
Practice Address - Country:US
Practice Address - Phone:805-748-8897
Practice Address - Fax:805-434-0308
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-30
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP8286363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
P65627Medicare UPIN
WNP8286AMedicare ID - Type Unspecified