Provider Demographics
NPI:1568620375
Name:ELMORE, DUDLEY G III (RN,FNP)
Entity Type:Individual
Prefix:
First Name:DUDLEY
Middle Name:G
Last Name:ELMORE
Suffix:III
Gender:M
Credentials:RN,FNP
Other - Prefix:
Other - First Name:DOUG
Other - Middle Name:G
Other - Last Name:ELMORE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:200 W ARBOR DRIVE
Practice Address - Street 2:MC 8401
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-8401
Practice Address - Country:US
Practice Address - Phone:619-543-5870
Practice Address - Fax:619-543-7785
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-29
Last Update Date:2018-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18199363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily