Provider Demographics
NPI:1881192417
Name:TANEDO, RONALDO CHINO PETALLO
Entity type:Individual
Prefix:
First Name:RONALDO
Middle Name:CHINO PETALLO
Last Name:TANEDO
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 1:3930 4TH AVE STE 300
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-3119
Mailing Address - Country:US
Mailing Address - Phone:619-320-8711
Mailing Address - Fax:619-393-0818
Practice Address - Street 1:3930 4TH AVE STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-3119
Practice Address - Country:US
Practice Address - Phone:619-320-8711
Practice Address - Fax:619-393-0818
Is Sole Proprietor?:No
Enumeration Date:2018-01-29
Last Update Date:2025-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA739150163W00000X
CA95032892363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse