Healthcare Provider Details

I. General information

NPI: 1669383204
Provider Name (Legal Business Name): EZRA-MICHAEL RYAN RODRIGUEZ LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/14/2026
Certification Date: 09/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1922 THE ALAMEDA STE 316
SAN JOSE CA
95126-1461
US

IV. Provider business mailing address

201 N GONZALEZ DR
HOLLISTER CA
95023-3648
US

V. Phone/Fax

Practice location:
  • Phone: 408-207-0565
  • Fax: 408-642-6052
Mailing address:
  • Phone: 408-310-3782
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number763532
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: