Provider Demographics
NPI:1932565181
Name:SOETJIPTO, THERESIA (MS,NP)
Entity Type:Individual
Prefix:MS
First Name:THERESIA
Middle Name:
Last Name:SOETJIPTO
Suffix:
Gender:F
Credentials:MS,NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:505 PARNASSUS AVE # M-361
Mailing Address - Street 2:CAMPUS BOX 0628
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94143-2204
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:505 PARNASSUS AVE # M-361
Practice Address - Street 2:CAMPUS BOX 0628
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2204
Practice Address - Country:US
Practice Address - Phone:415-353-1300
Practice Address - Fax:415-353-8570
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-04
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21074363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner