Healthcare Provider Details

I. General information

NPI: 1619477817
Provider Name (Legal Business Name): KRISTIAN WUYSANG
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/15/2018
Last Update Date: 06/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7965 SIERRA AVE STE E
FONTANA CA
92336
US

IV. Provider business mailing address

10850 CHURCH ST APT R106
RANCHO CUCAMONGA CA
91730-8051
US

V. Phone/Fax

Practice location:
  • Phone: 909-356-4459
  • Fax: 909-355-4261
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95007793
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: