Healthcare Provider Details

I. General information

NPI: 1982516100
Provider Name (Legal Business Name): ETHAN S ASUR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/22/2026
Last Update Date: 09/22/2026
Certification Date: 09/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19044 ARCHWOOD ST UNIT 8
RESEDA CA
91335-5124
US

IV. Provider business mailing address

19044 ARCHWOOD ST UNIT 8
RESEDA CA
91335-5124
US

V. Phone/Fax

Practice location:
  • Phone: 818-919-8413
  • Fax:
Mailing address:
  • Phone: 818-919-8413
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95041619
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: