Healthcare Provider Details

I. General information

NPI: 1407208846
Provider Name (Legal Business Name): MARY AZAH
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 02/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

160 E VIRGINIA ST STE 100
SAN JOSE CA
95112-5865
US

IV. Provider business mailing address

1724 SAMSON CT
SAN JOSE CA
95124-4600
US

V. Phone/Fax

Practice location:
  • Phone: 408-694-8463
  • Fax:
Mailing address:
  • Phone: 408-694-8463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005580
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number480700
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: