MEDICARE: NINA LU

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95018242	CA

General Provider Information

NPI Number	:	1205504842
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NINA LU

Provider Business Mailing Address
First Line	:	9505 AZOR LN
Second Line	:
City	:	ATASCADERO
State	:	CA
Zip	:	93422-6146
Country	:	US
Telephone Number	:	805-460-9653
Fax Number	:

Provider Business Practice Location Address
First Line	:	1111 LAS TABLAS RD STE N
Second Line	:
City	:	TEMPLETON
State	:	CA
Zip	:	93465-9732
Country	:	US
Telephone Number	:	805-434-1825
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/30/2021
Last Update Date	:	08/30/2021

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