Healthcare Provider Details

I. General information

NPI: 1457404816
Provider Name (Legal Business Name): NICHOLAS MONACO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2007
Last Update Date: 07/21/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 N BASCOM AVE STE 202
SAN JOSE CA
95128-1811
US

IV. Provider business mailing address

333 SANTANA ROW APT 237
SAN JOSE CA
95128-2008
US

V. Phone/Fax

Practice location:
  • Phone: 415-745-5665
  • Fax: 408-516-9377
Mailing address:
  • Phone: 415-745-5665
  • Fax: 408-516-9377

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberA54966
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberT2006-186
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: