Provider Demographics
NPI:1508156910
Name:BRINCKHAUS, NATHAN DARIO
Entity type:Individual
Prefix:
First Name:NATHAN
Middle Name:DARIO
Last Name:BRINCKHAUS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 NEWBURG RD
Mailing Address - Street 2:
Mailing Address - City:FORTUNA
Mailing Address - State:CA
Mailing Address - Zip Code:95540-2818
Mailing Address - Country:US
Mailing Address - Phone:707-617-2002
Mailing Address - Fax:833-941-4882
Practice Address - Street 1:2404 NEWBURG RD
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-2818
Practice Address - Country:US
Practice Address - Phone:707-617-2002
Practice Address - Fax:833-941-4882
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2024-12-19
Deactivation Date:2024-12-09
Deactivation Code:
Reactivation Date:2024-12-17
Provider Licenses
StateLicense IDTaxonomies
CAA124994207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program