Provider Demographics
NPI:1164666442
Name:DELAPEDRAJA, KYRA MARIE DOUGHERTY (PNP)
Entity Type:Individual
Prefix:
First Name:KYRA
Middle Name:MARIE DOUGHERTY
Last Name:DELAPEDRAJA
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:KYRA
Other - Middle Name:MARIE
Other - Last Name:DOUGHERTY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PNP
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:408-523-3640
Mailing Address - Fax:
Practice Address - Street 1:15400 LOS GATOS BLVD
Practice Address - Street 2:
Practice Address - City:LOS GATOS
Practice Address - State:CA
Practice Address - Zip Code:95032-2502
Practice Address - Country:US
Practice Address - Phone:408-523-3640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-30
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95002321363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO22678522Medicaid
COCOA103768Medicare PIN
CO22678522Medicaid