Provider Demographics
NPI:1295200038
Name:BUDIMAN, KARTIKA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KARTIKA
Middle Name:
Last Name:BUDIMAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3119 PARK VISTA DR
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-7100
Mailing Address - Country:US
Mailing Address - Phone:909-498-6274
Mailing Address - Fax:
Practice Address - Street 1:1450 E HOLT AVE
Practice Address - Street 2:
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91767-5822
Practice Address - Country:US
Practice Address - Phone:909-630-7927
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-08
Last Update Date:2021-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP950101068363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily