Healthcare Provider Details

I. General information

NPI: 1871726703
Provider Name (Legal Business Name): EDGAR JIMENEZ FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2009
Last Update Date: 10/05/2025
Certification Date: 10/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

UNIT 2060
APO AP
96278-2060
US

IV. Provider business mailing address

PSC 3 BOX 10411R
APO AP
96266-0105
US

V. Phone/Fax

Practice location:
  • Phone: 310-784-5603
  • Fax:
Mailing address:
  • Phone: 310-784-5603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number627728
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: