Provider Demographics
NPI:1609370543
Name:TANTOCO, NICOLE (MD, MPH)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:TANTOCO
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 POTRERO AVE # 6D
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94110-3518
Mailing Address - Country:US
Mailing Address - Phone:925-858-8100
Mailing Address - Fax:
Practice Address - Street 1:3288 MOANALUA RD
Practice Address - Street 2:
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96819-1469
Practice Address - Country:US
Practice Address - Phone:925-858-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-23
Last Update Date:2021-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA167321207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARES000Medicaid