Provider Demographics
NPI:1992969299
Name:GONZAGA, EDWIN OBUSAN (NURSE LVN)
Entity type:Individual
Prefix:MR
First Name:EDWIN
Middle Name:OBUSAN
Last Name:GONZAGA
Suffix:
Gender:M
Credentials:NURSE LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1488 KOOSER RD
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-3428
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1274 CITY VIEW PL
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95127-4333
Practice Address - Country:US
Practice Address - Phone:408-254-1040
Practice Address - Fax:408-251-8449
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-15
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN164609164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse