Provider Demographics
NPI:1003465105
Name:LISING, KENNETH PAOLO DAGDAG (MSN, APRN, FNP-C)
Entity Type:Individual
Prefix:
First Name:KENNETH PAOLO
Middle Name:DAGDAG
Last Name:LISING
Suffix:
Gender:M
Credentials:MSN, APRN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10283 JASMINE CT
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-8505
Mailing Address - Country:US
Mailing Address - Phone:714-262-1660
Mailing Address - Fax:
Practice Address - Street 1:2141 N HARBOR BLVD STE 25000
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835-3830
Practice Address - Country:US
Practice Address - Phone:714-626-8650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-11
Last Update Date:2021-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95012739363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily