MEDICARE: MRS. DONNA LAGDA MATHER NP

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	363LF0000X	Family Nurse Practitioner	95010964	CA

General Provider Information

NPI Number	:	1790243699
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. DONNA LAGDA MATHER NP

Provider Business Mailing Address
First Line	:	4670 ARIZONA ST APT 6
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-2918
Country	:	US
Telephone Number	:	619-254-8880
Fax Number	:

Provider Business Practice Location Address
First Line	:	4670 ARIZONA ST APT 6
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92116-2918
Country	:	US
Telephone Number	:	619-254-8880
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2019
Last Update Date	:	03/09/2019

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