Provider Demographics
NPI:1205171378
Name:URRUTIA, NICHOLAS DANIEL (MD)
Entity type:Individual
Prefix:DR
First Name:NICHOLAS
Middle Name:DANIEL
Last Name:URRUTIA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:355 CAMPUS DR
Mailing Address - Street 2:STE E
Mailing Address - City:HANFORD
Mailing Address - State:CA
Mailing Address - Zip Code:93230-4310
Mailing Address - Country:US
Mailing Address - Phone:559-584-0668
Mailing Address - Fax:559-584-1071
Practice Address - Street 1:355 CAMPUS DR
Practice Address - Street 2:STE E
Practice Address - City:HANFORD
Practice Address - State:CA
Practice Address - Zip Code:93230-4310
Practice Address - Country:US
Practice Address - Phone:559-584-0668
Practice Address - Fax:559-584-1071
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-30
Last Update Date:2013-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA122953207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA122953OtherMEDICARE
CAA122953Medicaid