Provider Demographics
NPI:1326738105
Name:KISHABA, KAMERON TOMOYA
Entity Type:Individual
Prefix:
First Name:KAMERON
Middle Name:TOMOYA
Last Name:KISHABA
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 1:31700 TEMECULA PKWY STE 2
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-5896
Mailing Address - Country:US
Mailing Address - Phone:951-600-4337
Mailing Address - Fax:
Practice Address - Street 1:7615 KENNEDY HL
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78235-4437
Practice Address - Country:US
Practice Address - Phone:210-283-6998
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2024-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program