Provider Demographics
NPI:1083203293
Name:BAGAMASPAD, JEFF R (RN)
Entity Type:Individual
Prefix:
First Name:JEFF
Middle Name:R
Last Name:BAGAMASPAD
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 1:1444 HORN CANYON AVE
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91915-1644
Mailing Address - Country:US
Mailing Address - Phone:619-402-3960
Mailing Address - Fax:
Practice Address - Street 1:400 E ST
Practice Address - Street 2:
Practice Address - City:CHULA VISTA
Practice Address - State:CA
Practice Address - Zip Code:91910-2413
Practice Address - Country:US
Practice Address - Phone:619-621-2622
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-12
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95085433163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse