Provider Demographics
NPI:1134171390
Name:RAYMOND, GARY MICHAEL (FNP)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:RAYMOND
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2641 KOA AVE
Mailing Address - Street 2:
Mailing Address - City:MORRO BAY
Mailing Address - State:CA
Mailing Address - Zip Code:93442-1709
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:47 SANTA ROSA ST
Practice Address - Street 2:47 SANTA ROSA
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93405-5816
Practice Address - Country:US
Practice Address - Phone:805-542-9596
Practice Address - Fax:805-594-1436
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA320850363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
P05914Medicare UPIN
CABP969WMedicare PIN