Healthcare Provider Details

I. General information

NPI: 1043382666
Provider Name (Legal Business Name): TINA ABOLHASSANI BLOOMER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 05/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4010 E CHAPMAN AVE SUITE C
ORANGE CA
92869-3990
US

IV. Provider business mailing address

19171 JASPER HILL RD
TRABUCO CANYON CA
92679-1121
US

V. Phone/Fax

Practice location:
  • Phone: 714-500-0358
  • Fax: 714-532-3943
Mailing address:
  • Phone: 949-633-9100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberRN 486773
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License NumberNP 10584
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: