Provider Demographics
NPI:1912464074
Name:CRUZ, MARC JEREMY (ACNPC-AG CRNFA)
Entity Type:Individual
Prefix:
First Name:MARC JEREMY
Middle Name:
Last Name:CRUZ
Suffix:
Gender:M
Credentials:ACNPC-AG CRNFA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1414 E MAIN ST STE 201
Mailing Address - Street 2:
Mailing Address - City:SANTA MARIA
Mailing Address - State:CA
Mailing Address - Zip Code:93454-4890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 OLD RIVER RD STE 200
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-9505
Practice Address - Country:US
Practice Address - Phone:661-663-6429
Practice Address - Fax:661-663-6041
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-25
Last Update Date:2021-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA674363163WR0006X
CA95012206363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WR0006XNursing Service ProvidersRegistered NurseRegistered Nurse First Assistant