Healthcare Provider Details

I. General information

NPI: 1235535170
Provider Name (Legal Business Name): JEREMY VERANGO AGNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/04/2014
Last Update Date: 04/15/2023
Certification Date: 04/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13851 E 14TH ST STE 102A
SAN LEANDRO CA
94578-2631
US

IV. Provider business mailing address

13851 E 14TH ST STE 102A
SAN LEANDRO CA
94578-2631
US

V. Phone/Fax

Practice location:
  • Phone: 510-357-1303
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP95001078
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: