Provider Demographics
NPI:1891256947
Name:MUTOPO, DEBRA (FNP)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:MUTOPO
Suffix:
Gender:F
Credentials:FNP
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 1569
Mailing Address - Street 2:
Mailing Address - City:SAN ANDREAS
Mailing Address - State:CA
Mailing Address - Zip Code:95249-1569
Mailing Address - Country:US
Mailing Address - Phone:209-745-3823
Mailing Address - Fax:
Practice Address - Street 1:900 MOUNTAIN RANCH RD
Practice Address - Street 2:
Practice Address - City:SAN ANDREAS
Practice Address - State:CA
Practice Address - Zip Code:95249-9713
Practice Address - Country:US
Practice Address - Phone:209-754-3823
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-29
Last Update Date:2019-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95010992363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily