Healthcare Provider Details

I. General information

NPI: 1639521065
Provider Name (Legal Business Name): AIDA DIZDAREVIC FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2016
Last Update Date: 09/18/2023
Certification Date: 09/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1250 COLLINS LN
SAN JOSE CA
95129-4208
US

IV. Provider business mailing address

1250 COLLINS LN
SAN JOSE CA
95129-4208
US

V. Phone/Fax

Practice location:
  • Phone: 408-973-9992
  • Fax:
Mailing address:
  • Phone: 408-973-9992
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95005637
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number601774
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: