Provider Demographics
NPI:1750199543
Name:FAMADOR, ALICE CORPUZ (AGNP)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:CORPUZ
Last Name:FAMADOR
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2417 PASEO LOS GATOS
Mailing Address - Street 2:
Mailing Address - City:CHULA VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:91914-4431
Mailing Address - Country:US
Mailing Address - Phone:619-395-0300
Mailing Address - Fax:
Practice Address - Street 1:1320 E MADISON AVE
Practice Address - Street 2:
Practice Address - City:EL CAJON
Practice Address - State:CA
Practice Address - Zip Code:92021-8531
Practice Address - Country:US
Practice Address - Phone:619-456-9800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-25
Last Update Date:2024-12-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAG12240042363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology