Healthcare Provider Details

I. General information

NPI: 1932937174
Provider Name (Legal Business Name): GERMAN BADILLA GORDOVE JR. RN, PCCN, AGACNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2024
Last Update Date: 09/17/2024
Certification Date: 09/17/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2315 STOCKTON BLVD
SACRAMENTO CA
95817-2201
US

IV. Provider business mailing address

3375 ALMA ST APT 181
PALO ALTO CA
94306-3517
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-5590
  • Fax:
Mailing address:
  • Phone: 406-240-4876
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number95030128
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95030128
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: