Healthcare Provider Details

I. General information

NPI: 1679919138
Provider Name (Legal Business Name): JOHN BREDIN BOGGS ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/10/2013
Last Update Date: 12/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1661 SOQUEL DR STE D
SANTA CRUZ CA
95065-1709
US

IV. Provider business mailing address

325 DISTEL CIR
LOS ALTOS CA
94022-1408
US

V. Phone/Fax

Practice location:
  • Phone: 831-460-6041
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number22924
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: