Healthcare Provider Details

I. General information

NPI: 1437817434
Provider Name (Legal Business Name): JOHN FUJIWARA NP-C PMHNP-BC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/07/2021
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8275 S EASTERN AVE STE 200-175
LAS VEGAS NV
89123-2591
US

IV. Provider business mailing address

877 ROANOKE RD
SAN MARINO CA
91108-2437
US

V. Phone/Fax

Practice location:
  • Phone: 702-758-4708
  • Fax:
Mailing address:
  • Phone: 626-348-4458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: JOHN FUJIWARA
Title or Position: PRESIDENT/PROVIDER
Credential: NP-C PMHNP-BC
Phone: 702-758-4708