Provider Demographics
NPI:1871174748
Name:SNIDER, IAN FOSTER (PMHNP)
Entity type:Individual
Prefix:MR
First Name:IAN
Middle Name:FOSTER
Last Name:SNIDER
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4175 WABASH AVE UNIT 1
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92104-2140
Mailing Address - Country:US
Mailing Address - Phone:310-922-6367
Mailing Address - Fax:
Practice Address - Street 1:5555 RESERVOIR DR STE 204-A
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-5134
Practice Address - Country:US
Practice Address - Phone:619-822-1800
Practice Address - Fax:619-839-3872
Is Sole Proprietor?:No
Enumeration Date:2021-04-21
Last Update Date:2025-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95119190163WP0808X
CA95023071363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health