Provider Demographics
NPI:1013756154
Name:DEREGO, TIMOTHY JAMES (FNP-C)
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:JAMES
Last Name:DEREGO
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-764-3000
Mailing Address - Fax:
Practice Address - Street 1:3811 VALLEY CENTRE DR # S99
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92130-3318
Practice Address - Country:US
Practice Address - Phone:858-764-3000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-20
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028760363L00000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care