Healthcare Provider Details

I. General information

NPI: 1194403816
Provider Name (Legal Business Name): ANDREA OGDEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/11/2023
Certification Date: 10/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4356 W POINT LOMA BLVD APT N
SAN DIEGO CA
92107-1172
US

IV. Provider business mailing address

4356 W POINT LOMA BLVD APT N
SAN DIEGO CA
92107-1172
US

V. Phone/Fax

Practice location:
  • Phone: 831-498-3594
  • Fax:
Mailing address:
  • Phone: 831-498-3594
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: