Provider Demographics
NPI:1134277254
Name:HERMANSEN, GARY KEITH (NP)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:KEITH
Last Name:HERMANSEN
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 1:308 DONAHUE ST
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94965-1032
Mailing Address - Country:US
Mailing Address - Phone:415-535-3659
Mailing Address - Fax:
Practice Address - Street 1:308 DONAHUE ST
Practice Address - Street 2:
Practice Address - City:SAUSALITO
Practice Address - State:CA
Practice Address - Zip Code:94965-1032
Practice Address - Country:US
Practice Address - Phone:415-535-3659
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-08
Last Update Date:2019-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT7066932-8900363LP0808X
MS1008111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No111N00000XChiropractic ProvidersChiropractor