Provider Demographics
NPI:1154915858
Name:DE LA GUARDIA, JOSIE LAUREN BASS (NP)
Entity type:Individual
Prefix:
First Name:JOSIE
Middle Name:LAUREN BASS
Last Name:DE LA GUARDIA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 5TH ST UNIT 449
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94710-1878
Mailing Address - Country:US
Mailing Address - Phone:404-694-9942
Mailing Address - Fax:
Practice Address - Street 1:2213 BUCHANAN RD STE 103
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94509-4265
Practice Address - Country:US
Practice Address - Phone:925-303-4780
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95235981207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine