Healthcare Provider Details

I. General information

NPI: 1548997422
Provider Name (Legal Business Name): GLORIFINO DEGALA JUAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/02/2022
Last Update Date: 12/21/2023
Certification Date: 12/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

847 W CHILDS AVE STE A
MERCED CA
95341-6862
US

IV. Provider business mailing address

737 W CHILDS AVE
MERCED CA
95341-6805
US

V. Phone/Fax

Practice location:
  • Phone: 209-384-6481
  • Fax:
Mailing address:
  • Phone: 209-384-6481
  • Fax: 209-359-2045

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP025962
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95027233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: