Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 20112 | CA |
NPI | 1003114372 |
---|---|
Provider Name | Greg Roussett |
First Address | Oakland, CA 94612-1605 |
Second Address | San Francisco, CA 94102 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/03/2011 |
Last Update Date | 10/09/2019 |