=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255106282
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | USTINA WASIF
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/20/2023
-----------------------------------------------------
Last Update Date | 11/20/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2743 FAITH ST
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92882-5970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-858-1596
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2743 FAITH ST
-----------------------------------------------------
City | CORONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92882-5970
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-858-1596
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 152W00000X
-----------------------------------------------------
Taxonomy Name | Optometrist
-----------------------------------------------------
License Number | OPT35592-TLG
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------