Healthcare Provider Details

I. General information

NPI: 1164862207
Provider Name (Legal Business Name): MR. NICK GONZALES SAZON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

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

III. Provider practice location address

3400 TARAWA RD
SAN DIEGO CA
92155-5176
US

IV. Provider business mailing address

3400 TARAWA RD
SAN DIEGO CA
92155-5176
US

V. Phone/Fax

Practice location:
  • Phone: 619-437-5540
  • Fax:
Mailing address:
  • Phone: 619-437-5540
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: