Healthcare Provider Details

I. General information

NPI: 1568730539
Provider Name (Legal Business Name): ELSJE E BOS GURKO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2011
Last Update Date: 12/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3031 TISCH WAY SUITE 306
SAN JOSE CA
95128-2541
US

IV. Provider business mailing address

3031 TISCH WAY SUITE 306
SAN JOSE CA
95128-2541
US

V. Phone/Fax

Practice location:
  • Phone: 408-857-1122
  • Fax: 408-554-4209
Mailing address:
  • Phone: 408-857-1122
  • Fax: 408-554-4209

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: