Provider Demographics
NPI:1437528858
Name:CUNANAN, MARTIN DWIGHT (AGNP, PMHNP)
Entity Type:Individual
Prefix:
First Name:MARTIN DWIGHT
Middle Name:
Last Name:CUNANAN
Suffix:
Gender:M
Credentials:AGNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1227 WILLARD ST
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94117-3704
Mailing Address - Country:US
Mailing Address - Phone:503-308-8040
Mailing Address - Fax:415-480-8278
Practice Address - Street 1:100 BUSH ST STE 1428
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94104-3916
Practice Address - Country:US
Practice Address - Phone:415-843-1523
Practice Address - Fax:415-484-7083
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-15
Last Update Date:2023-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR202203363NP-PP363LG0600X
OR202203889NP-PP363LP0808X
CA95003125363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health