Provider Demographics
NPI:1275331779
Name:BAGIS, IMELDA CASTRO
Entity type:Individual
Prefix:
First Name:IMELDA
Middle Name:CASTRO
Last Name:BAGIS
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1433 LITTLE ORCHARD ST
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95110-3502
Mailing Address - Country:US
Mailing Address - Phone:408-219-5202
Mailing Address - Fax:
Practice Address - Street 1:1433 LITTLE ORCHARD ST
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-3502
Practice Address - Country:US
Practice Address - Phone:408-219-5202
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-03-03
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANPF95027827363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily