MEDICARE: MR. KLAR FULGENTES PASILABAN FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95004610	CA
2	363LP2300X	Primary Care Nurse Practitioner	813583	NV
3	363LP2300X	Primary Care Nurse Practitioner	54130	NM
4	363LP2300X	Primary Care Nurse Practitioner	95004610	CA
5	363LP2300X	Primary Care Nurse Practitioner	AP61019951	WA
6	363LP2300X	Primary Care Nurse Practitioner	202005274NP-PP	OR
7	363LP2300X	Primary Care Nurse Practitioner	219427	AZ

General Provider Information

NPI Number	:	1104371806
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. KLAR FULGENTES PASILABAN FNP

Provider Business Mailing Address
First Line	:	1822 SPRINGGATE LN APT G
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-2982
Country	:	US
Telephone Number	:	805-256-7828
Fax Number	:

Provider Business Practice Location Address
First Line	:	1822 SPRINGGATE LN APT G
Second Line	:
City	:	SIMI VALLEY
State	:	CA
Zip	:	93065-2982
Country	:	US
Telephone Number	:	805-256-7828
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/23/2016
Last Update Date	:	07/21/2020

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