Healthcare Provider Details

I. General information

NPI: 1700714383
Provider Name (Legal Business Name): PORVENIR TAN II NP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/12/2026
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1331 W AVENUE J # 101
LANCASTER CA
93534-2942
US

IV. Provider business mailing address

27507 SPENCER CT APT 202
CANYON COUNTRY CA
91387-6698
US

V. Phone/Fax

Practice location:
  • Phone: 661-381-4213
  • Fax:
Mailing address:
  • Phone: 661-955-2031
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95039511
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: