Healthcare Provider Details

I. General information

NPI: 1720052467
Provider Name (Legal Business Name): KARLA AUGUSTIN
Entity Type: Individual
Gender: Female
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

TRICARE OUTPATIENT CLINIC 8808 BALBOA AVE.
SAN DIEGO CA
92123
US

IV. Provider business mailing address

TRICARE OUTPATIENT CLINIC 8808 BALBOA AVE.
SAN DIEGO CA
92123
US

V. Phone/Fax

Practice location:
  • Phone: 858-569-6664
  • Fax:
Mailing address:
  • Phone: 858-569-6664
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number470454
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: