Basic Information
| Provider Information | |||||||||
| NPI: | 1245709112 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEGUZMAN | ||||||||
| FirstName: | DARRELL | ||||||||
| MiddleName: | VINCECRUZ | ||||||||
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| Credential: | PMHNP, FNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 609001 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921609001 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195284600 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1061 TIERRA DEL REY STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHULA VISTA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6194985454 | ||||||||
| FaxNumber: | 6195284625 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/20/2018 | ||||||||
| LastUpdateDate: | 05/13/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95008025 | CA | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | NP95008025 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | W416 | 05 | CA | MEDICAID |