Healthcare Provider Details

I. General information

NPI: 1194291351
Provider Name (Legal Business Name): REGINA TABORA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/15/2018
Last Update Date: 11/05/2022
Certification Date: 11/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-0002
US

IV. Provider business mailing address

12425 ROBISON BLVD
POWAY CA
92064-4319
US

V. Phone/Fax

Practice location:
  • Phone: 858-552-8585
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95022591
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95150323
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: