Healthcare Provider Details

I. General information

NPI: 1174377733
Provider Name (Legal Business Name): NADIA KEDDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2024
Last Update Date: 04/11/2024
Certification Date: 04/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

769 MEDICAL CENTER CT STE 202
CHULA VISTA CA
91911-6602
US

IV. Provider business mailing address

769 MEDICAL CENTER CT STE 202
CHULA VISTA CA
91911-6602
US

V. Phone/Fax

Practice location:
  • Phone: 619-482-8430
  • Fax:
Mailing address:
  • Phone: 619-482-8430
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number64334
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: