Healthcare Provider Details

I. General information

NPI: 1891727699
Provider Name (Legal Business Name): EDGAR OLIVER SAN LUIS MSN, FNP-BC, FAANP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 08/05/2025
Certification Date: 08/05/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8808 BALBOA AVE
SAN DIEGO CA
92123-1592
US

IV. Provider business mailing address

8808 BALBOA AVE
SAN DIEGO CA
92123-1592
US

V. Phone/Fax

Practice location:
  • Phone: 619-645-0155
  • Fax: 619-645-0193
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-2027
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number13312
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: