=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821852203
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ANDREW CHARLES BLISS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/07/2024
-----------------------------------------------------
Last Update Date | 03/31/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2707 E VALLEY BLVD STE 116
-----------------------------------------------------
City | WEST COVINA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91792-3196
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 626-581-1000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1601 CENTINELA AVE STE 5-M1024
-----------------------------------------------------
City | INGLEWOOD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90302-1076
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 310-902-0538
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | F12230868
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------