MEDICARE: MOBILE WOUND CARE-SAN DIEGO ND

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AM0700X	Medical Physician Assistant	54015	CA

General Provider Information

NPI Number	:	1295273639
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE WOUND CARE-SAN DIEGO ND

Provider Business Mailing Address
First Line	:	1415 SANTA DIANA RD UNIT 9
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91913-2745
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1415 SANTA DIANA RD
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91913-2745
Country	:	US
Telephone Number	:	702-927-3599
Fax Number	:

Authorized Official
Title or Position	:	PHYSICIAN ASSISTANT- CERTIFIED
Name	:	NHI DAI
Credential	:	PA-C
Telephone Number	:	702-927-3599

Provider Enumeration Date	:	02/06/2017
Last Update Date	:	02/07/2017

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