Provider Demographics
NPI:1346754025
Name:MBAWA, ISATA S (LPT)
Entity Type:Individual
Prefix:MS
First Name:ISATA
Middle Name:S
Last Name:MBAWA
Suffix:
Gender:F
Credentials:LPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4987 SPEAK LN
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-2767
Mailing Address - Country:US
Mailing Address - Phone:408-417-1164
Mailing Address - Fax:
Practice Address - Street 1:4987 SPEAK LN
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-2767
Practice Address - Country:US
Practice Address - Phone:408-417-1164
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-16
Last Update Date:2017-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37848167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA16127819OtherKAISER PERMANENTE