Basic Information
Provider Information | |||||||||
NPI: | 1346386893 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | NORDGREN | ||||||||
FirstName: | JULIA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | BOSSUNG | ||||||||
OtherFirstName: | JULIA | ||||||||
OtherMiddleName: | R | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 325 DISTEL CIR | ||||||||
Address2: |   | ||||||||
City: | LOS ALTOS | ||||||||
State: | CA | ||||||||
PostalCode: | 940221408 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 795 EL CAMINO REAL | ||||||||
Address2: |   | ||||||||
City: | PALO ALTO | ||||||||
State: | CA | ||||||||
PostalCode: | 943012302 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6508532992 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/30/2007 | ||||||||
LastUpdateDate: | 05/29/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/29/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | C137012 | CA | Y |   | Allopathic & Osteopathic Physicians | Pediatrics |   | 2080A0000X | 11456 | NH | N |   | Allopathic & Osteopathic Physicians | Pediatrics | Adolescent Medicine |
ID Information
ID | Type | State | Issuer | Description | 30203087 | 05 | NH |   | MEDICAID |