Healthcare Provider Details

I. General information

NPI: 1659301000
Provider Name (Legal Business Name): IGOR M BEDEROV NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

262 BONITA LN
FOSTER CITY CA
94404-1982
US

IV. Provider business mailing address

262 BONITA LN
FOSTER CITY CA
94404-1982
US

V. Phone/Fax

Practice location:
  • Phone: 650-571-9090
  • Fax:
Mailing address:
  • Phone: 650-571-9090
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN586047
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP21555
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: