Provider Demographics
NPI:1073814372
Name:TICZON, ROBERT (RN)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:
Last Name:TICZON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 PALM VALLEY BLVD
Mailing Address - Street 2:#1120
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95123-1060
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:333 W SAN CARLOS ST
Practice Address - Street 2:SUITE 1680
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95110-2726
Practice Address - Country:US
Practice Address - Phone:408-287-5007
Practice Address - Fax:408-287-3505
Is Sole Proprietor?:No
Enumeration Date:2010-11-03
Last Update Date:2010-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA622125163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse