Healthcare Provider Details

I. General information

NPI: 1609059062
Provider Name (Legal Business Name): MARICELA E AGUARISTI PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2007
Last Update Date: 12/30/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

455 OCONNOR DR SUITE 390
SAN JOSE CA
95128-1633
US

IV. Provider business mailing address

455 OCONNOR DR SUITE 390
SAN JOSE CA
95128-1633
US

V. Phone/Fax

Practice location:
  • Phone: 408-918-0405
  • Fax: 408-918-0409
Mailing address:
  • Phone: 408-918-0405
  • Fax: 408-918-0409

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA19397
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: