Healthcare Provider Details

I. General information

NPI: 1922785856
Provider Name (Legal Business Name): TYLER TABOADA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 07/03/2023
Certification Date: 07/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2295 PLUMMER AVE
SAN JOSE CA
95125-4767
US

IV. Provider business mailing address

243 OMIRA DR
SAN JOSE CA
95123-3633
US

V. Phone/Fax

Practice location:
  • Phone: 408-269-0701
  • Fax:
Mailing address:
  • Phone: 408-771-9649
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number302308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: