Provider Demographics
NPI:1962263285
Name:LEDEZMA-GARCIA, STEPHANNY
Entity type:Individual
Prefix:
First Name:STEPHANNY
Middle Name:
Last Name:LEDEZMA-GARCIA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10628 STORY LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95127-4334
Mailing Address - Country:US
Mailing Address - Phone:408-398-9401
Mailing Address - Fax:
Practice Address - Street 1:3155 KEARNEY ST STE 100
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-2268
Practice Address - Country:US
Practice Address - Phone:510-931-4310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-23
Last Update Date:2024-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 390200000X
CAPA64294363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program