Provider Demographics
NPI:1659301000
Name:BEDEROV, IGOR M (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:IGOR
Middle Name:M
Last Name:BEDEROV
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:262 BONITA LN
Mailing Address - Street 2:
Mailing Address - City:FOSTER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94404-1982
Mailing Address - Country:US
Mailing Address - Phone:650-571-9090
Mailing Address - Fax:
Practice Address - Street 1:262 BONITA LN
Practice Address - Street 2:
Practice Address - City:FOSTER CITY
Practice Address - State:CA
Practice Address - Zip Code:94404-1982
Practice Address - Country:US
Practice Address - Phone:650-571-9090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2013-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN586047163W00000X
CANP21555363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGG066AMedicare UPIN