Provider Demographics
NPI:1982705901
Name:SCULLON, DEBORAH IRENE (CRNA,BSN)
Entity Type:Individual
Prefix:MS
First Name:DEBORAH
Middle Name:IRENE
Last Name:SCULLON
Suffix:
Gender:F
Credentials:CRNA,BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:866 OLD QUARRY RD S
Mailing Address - Street 2:
Mailing Address - City:LARKSPUR
Mailing Address - State:CA
Mailing Address - Zip Code:94939-2218
Mailing Address - Country:US
Mailing Address - Phone:415-531-6879
Mailing Address - Fax:
Practice Address - Street 1:4150 CLEMENT ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94121-1545
Practice Address - Country:US
Practice Address - Phone:415-750-2069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-25
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA407480163W00000X
CA1052367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABO476RMedicare PIN
CAZZZ34009ZMedicare PIN