MEDICARE: MR. PRINCE OCANSEY 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	NP21235	CA

General Provider Information

NPI Number	:	1164708640
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. PRINCE OCANSEY FNP

Provider Business Mailing Address
First Line	:	9415 MISSION BLVD STE P
Second Line	:
City	:	JURUPA VALLEY
State	:	CA
Zip	:	92509-2600
Country	:	US
Telephone Number	:	833-865-8263
Fax Number	:	951-742-8687

Provider Business Practice Location Address
First Line	:	1050 KENDALL DR STE F
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92407-4125
Country	:	US
Telephone Number	:	909-352-6655
Fax Number	:

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

Provider Enumeration Date	:	10/27/2011
Last Update Date	:	08/22/2023

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