Healthcare Provider Details

I. General information

NPI: 1902106982
Provider Name (Legal Business Name): METAMORPH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2010
Last Update Date: 10/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7725 KILMARNOK DR
SAN JOSE CA
95135-2140
US

IV. Provider business mailing address

7725 KILMARNOK DR
SAN JOSE CA
95135-2140
US

V. Phone/Fax

Practice location:
  • Phone: 408-852-0703
  • Fax:
Mailing address:
  • Phone: 408-852-0703
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number17859
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number17859
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number17859
License Number StateCA

VIII. Authorized Official

Name: PHYLLIS N BORNER
Title or Position: PRESIDENT
Credential:
Phone: 408-852-0703