Provider Demographics
NPI:1215535034
Name:JOHN, SHIJI
Entity Type:Individual
Prefix:
First Name:SHIJI
Middle Name:
Last Name:JOHN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3765 GUNNISON CIR
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92881-8486
Mailing Address - Country:US
Mailing Address - Phone:714-329-3869
Mailing Address - Fax:
Practice Address - Street 1:3765 GUNNISON CIR
Practice Address - Street 2:
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92881-8486
Practice Address - Country:US
Practice Address - Phone:714-329-3869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-14
Last Update Date:2020-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95014721363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA678424OtherBOARD OF REGISTERED NURSES, LICENCE