Basic Information
| Provider Information | |||||||||
| NPI: | 1639777105 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HOOPER | ||||||||
| FirstName: | FORREST | ||||||||
| MiddleName: | GLON | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8881 FLETCHER PKWY STE 205 | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192704388 | ||||||||
| FaxNumber: | 6199373767 | ||||||||
| Practice Location | |||||||||
| Address1: | 8881 FLETCHER PKWY STE 205 | ||||||||
| Address2: | |||||||||
| City: | LA MESA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 919423187 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192704388 | ||||||||
| FaxNumber: | 6199373767 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/15/2020 | ||||||||
| LastUpdateDate: | 11/04/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/04/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2200X | 95013348 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 95013348 | 01 | CA | NURSE PRACTITIONER/FURNISHING NUMBER | OTHER |