Provider Demographics
NPI:1639777105
Name:HOOPER, FORREST GLON (NP)
Entity Type:Individual
Prefix:MR
First Name:FORREST
Middle Name:GLON
Last Name:HOOPER
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 1:8881 FLETCHER PKWY STE 205
Mailing Address - Street 2:
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-3187
Mailing Address - Country:US
Mailing Address - Phone:619-270-4388
Mailing Address - Fax:619-937-3767
Practice Address - Street 1:8881 FLETCHER PKWY STE 205
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-3187
Practice Address - Country:US
Practice Address - Phone:619-270-4388
Practice Address - Fax:619-937-3767
Is Sole Proprietor?:No
Enumeration Date:2020-10-15
Last Update Date:2020-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95013348363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95013348OtherNURSE PRACTITIONER/FURNISHING NUMBER