=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528015849
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BRIAN PAUL MITU F.N.P., P.A.-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/30/2006
-----------------------------------------------------
Last Update Date | 02/25/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29409 S WESTERN AVE
-----------------------------------------------------
City | RANCHO PALOS VERDES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90275-1137
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-891-6684
-----------------------------------------------------
Fax | 310-514-4903
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2803 GRAMERCY AVE
-----------------------------------------------------
City | TORRANCE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90501-5431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-869-1218
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 18341
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 16318
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number | 16318
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------