Healthcare Provider Details

I. General information

NPI: 1942080593
Provider Name (Legal Business Name): CASEY DYAN ESCOBEDO AGNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 10/02/2023
Certification Date: 10/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

222 N PACIFIC COAST HWY STE 1420
EL SEGUNDO CA
90245-5648
US

IV. Provider business mailing address

222 N PACIFIC COAST HWY STE 2175
EL SEGUNDO CA
90245-5639
US

V. Phone/Fax

Practice location:
  • Phone: 877-878-3289
  • Fax: 877-817-3227
Mailing address:
  • Phone: 877-878-3289
  • Fax: 877-817-3227

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number1136669
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: