=====================================================
General NPI Number Information
=====================================================
NPI Number | 1720245699
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NETTIE NG P.A.-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/19/2008
-----------------------------------------------------
Last Update Date | 04/22/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 OCONNOR DR SUITE 290
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-998-5400
-----------------------------------------------------
Fax | 408-998-5414
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 OCONNOR DR SUITE 290
-----------------------------------------------------
City | SAN JOSE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95128-1633
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 408-998-5400
-----------------------------------------------------
Fax | 408-998-5414
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA19678
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------