MEDICARE: AIDA JOSEF MERCADO-AGUSTIN RN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	407795	CA

General Provider Information

NPI Number	:	1578806600
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AIDA JOSEF MERCADO-AGUSTIN RN

Provider Business Mailing Address
First Line	:	13352 THUNDERHEAD ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92129-2330
Country	:	US
Telephone Number	:	858-610-7149
Fax Number	:	858-206-5241

Provider Business Practice Location Address
First Line	:	13352 THUNDERHEAD ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92129-2330
Country	:	US
Telephone Number	:	858-610-7149
Fax Number	:	858-206-5241

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/27/2013
Last Update Date	:	03/27/2013

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