Healthcare Provider Details

I. General information

NPI: 1104371806
Provider Name (Legal Business Name): KLAR FULGENTES PASILABAN FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2016
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1822 SPRINGGATE LN APT G
SIMI VALLEY CA
93065-2982
US

IV. Provider business mailing address

1822 SPRINGGATE LN APT G
SIMI VALLEY CA
93065-2982
US

V. Phone/Fax

Practice location:
  • Phone: 805-256-7828
  • Fax:
Mailing address:
  • Phone: 805-256-7828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95004610
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number813583
License Number StateNV
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number54130
License Number StateNM
# 4
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number95004610
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP61019951
License Number StateWA
# 6
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number202005274NP-PP
License Number StateOR
# 7
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number219427
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: