Provider Demographics
NPI:1275194599
Name:FERNANDO, NUWAN
Entity Type:Individual
Prefix:
First Name:NUWAN
Middle Name:
Last Name:FERNANDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17861 VON KARMAN AVE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6213
Mailing Address - Country:US
Mailing Address - Phone:951-365-3840
Mailing Address - Fax:
Practice Address - Street 1:17861 VON KARMAN AVE
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6213
Practice Address - Country:US
Practice Address - Phone:951-365-3840
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-26
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes103K00000XBehavioral Health & Social Service ProvidersBehavior Analyst