Healthcare Provider Details

I. General information

NPI: 1932349230
Provider Name (Legal Business Name): MYRNA LIZ ALIVIO GAGANTE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/26/2009
Last Update Date: 02/26/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 FOREST AVE SUITE 100
SAN JOSE CA
95128-4833
US

IV. Provider business mailing address

2030 FOREST AVE SUITE 100
SAN JOSE CA
95128-4833
US

V. Phone/Fax

Practice location:
  • Phone: 408-947-2929
  • Fax:
Mailing address:
  • Phone: 408-947-2929
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number17697
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: