Healthcare Provider Details

I. General information

NPI: 1558061051
Provider Name (Legal Business Name): PHILLIP OGANESYAN FNP-C, MSN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

435 ARDEN AVE STE 550
GLENDALE CA
91203-4026
US

IV. Provider business mailing address

11127 WICKS ST
SUN VALLEY CA
91352-1245
US

V. Phone/Fax

Practice location:
  • Phone: 818-242-3916
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95024485
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: