Healthcare Provider Details

I. General information

NPI: 1164037644
Provider Name (Legal Business Name): MATTHEW ANG LY NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2020
Last Update Date: 09/11/2020
Certification Date: 08/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

725 WELCH RD
PALO ALTO CA
94304-1601
US

IV. Provider business mailing address

5383 KING ESTATES CT
SAN JOSE CA
95135-1365
US

V. Phone/Fax

Practice location:
  • Phone: 650-497-8800
  • Fax:
Mailing address:
  • Phone: 408-904-9805
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number95015297
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: