Healthcare Provider Details

I. General information

NPI: 1710604525
Provider Name (Legal Business Name): VICMAR BURGONIO FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/24/2022
Last Update Date: 08/12/2026
Certification Date: 08/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3620 LONG BEACH BLVD STE C3
LONG BEACH CA
90807-6009
US

IV. Provider business mailing address

4330 E MIRALOMA AVE
ANAHEIM CA
92807-1886
US

V. Phone/Fax

Practice location:
  • Phone: 661-313-2166
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95022430
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95022430
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: