Healthcare Provider Details

I. General information

NPI: 1104714963
Provider Name (Legal Business Name): BLUE SKY SURGICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/27/2025
Last Update Date: 11/15/2025
Certification Date: 11/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2951 WALL ST
SAN JOSE CA
95111-4600
US

IV. Provider business mailing address

2951 WALL ST
SAN JOSE CA
95111-4600
US

V. Phone/Fax

Practice location:
  • Phone: 408-603-6553
  • Fax:
Mailing address:
  • Phone: 650-935-4745
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JENNY PHAN
Title or Position: OWNER
Credential:
Phone: 650-935-4745