Healthcare Provider Details

I. General information

NPI: 1487381059
Provider Name (Legal Business Name): BRANDON CHANG HWUN RO MSN, PMHNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2022
Last Update Date: 09/03/2024
Certification Date: 09/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5565 GROSSMONT CENTER DR STE 229
LA MESA CA
91942-3026
US

IV. Provider business mailing address

5565 GROSSMONT CENTER DR STE 229
LA MESA CA
91942-3026
US

V. Phone/Fax

Practice location:
  • Phone: 858-342-4572
  • Fax:
Mailing address:
  • Phone: 858-342-4572
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number95207609
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95029635
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: