Provider Demographics
NPI:1225784481
Name:GARCIA MORA, EDGAR ALEXIS
Entity Type:Individual
Prefix:
First Name:EDGAR
Middle Name:ALEXIS
Last Name:GARCIA MORA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:349 MANZANITA DR
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:CA
Mailing Address - Zip Code:95492-7439
Mailing Address - Country:US
Mailing Address - Phone:707-498-0157
Mailing Address - Fax:
Practice Address - Street 1:17000 ARNOLD DR
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-3242
Practice Address - Country:US
Practice Address - Phone:707-933-4482
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-26
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95197927163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse