Healthcare Provider Details

I. General information

NPI: 1124846134
Provider Name (Legal Business Name): MYRON UBUNGEN MSN RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/30/2024
Last Update Date: 09/30/2024
Certification Date: 09/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 E TAYLOR ST # 5
SAN JOSE CA
95112-3127
US

IV. Provider business mailing address

1559 DELUCA DR
SAN JOSE CA
95131-3026
US

V. Phone/Fax

Practice location:
  • Phone: 669-250-1515
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number95060893
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: