Provider Demographics
NPI:1255061172
Name:PATAWARAN, MYRA
Entity type:Individual
Prefix:
First Name:MYRA
Middle Name:
Last Name:PATAWARAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MYRA
Other - Middle Name:
Other - Last Name:MANALASTAS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1775 STORY RD STE 120
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95122-1942
Mailing Address - Country:US
Mailing Address - Phone:408-817-6894
Mailing Address - Fax:
Practice Address - Street 1:1775 STORY RD STE 120
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95122-1942
Practice Address - Country:US
Practice Address - Phone:408-817-6894
Practice Address - Fax:408-494-1557
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-14
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95218035163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management