Healthcare Provider Details

I. General information

NPI: 1407434533
Provider Name (Legal Business Name): MOENA NISHIKAWA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2021
Last Update Date: 10/18/2024
Certification Date: 10/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2067 W VISTA WAY STE 180
VISTA CA
92083-6033
US

IV. Provider business mailing address

2067 W VISTA WAY STE 180
VISTA CA
92083-6033
US

V. Phone/Fax

Practice location:
  • Phone: 760-945-3434
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA194171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: