Provider Demographics
NPI:1356061089
Name:GRADO-GONZALEZ, MINERVA
Entity type:Individual
Prefix:
First Name:MINERVA
Middle Name:
Last Name:GRADO-GONZALEZ
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4202 43RD ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92105-1202
Mailing Address - Country:US
Mailing Address - Phone:619-549-9845
Mailing Address - Fax:
Practice Address - Street 1:15190 SEGOVIA CT
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92129-1219
Practice Address - Country:US
Practice Address - Phone:661-378-2789
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-09-01
Last Update Date:2022-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA9702240OtherDRIVER LICENSE