Basic Information
| Provider Information | |||||||||
| NPI: | 1417205527 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NAKKERUD-WHITESIDE | ||||||||
| FirstName: | BRIAN | ||||||||
| MiddleName: | JAMES | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, PMHFNPC | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NAKKERUD-WHITESIDE | ||||||||
| OtherFirstName: | BRIAN | ||||||||
| OtherMiddleName: | JAMES | ||||||||
| OtherNamePrefix: | MR. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN, PMHFNPC | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544170 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Practice Location | |||||||||
| Address1: | 1400 EMELINE AVE | ||||||||
| Address2: | |||||||||
| City: | SANTA CRUZ | ||||||||
| State: | CA | ||||||||
| PostalCode: | 950601976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8314544170 | ||||||||
| FaxNumber: | 8314544663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/21/2012 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 802020 | CA | N | Nursing Service Providers | Registered Nurse | 363LP0808X | 87055 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health | 363LP0808X | 23511 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | ZZZ91891Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER | FHC70042F | 01 | CA | MEDI-CAL PTAN GROUP# | OTHER | ZZZ92069Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER | FHC70044F | 01 | CA | MEDI-CAL PTAN GROUP# | OTHER | ZZZ91892Z | 01 | CA | SANTA CRUZ COUNTY MEDICARE GROUP PTAN# | OTHER |