Healthcare Provider Details

I. General information

NPI: 1114329612
Provider Name (Legal Business Name): PARIS KANTAS FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/16/2014
Last Update Date: 09/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

705 PALM AVE
IMPERIAL BEACH CA
91932-1229
US

IV. Provider business mailing address

689 REDLANDS PL
BONITA CA
91902-4017
US

V. Phone/Fax

Practice location:
  • Phone: 619-424-5106
  • Fax:
Mailing address:
  • Phone: 619-889-8900
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number18661
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: