Provider Demographics
NPI:1477066132
Name:KANLILAR-RUIZ, BASAK JULIA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:BASAK
Middle Name:JULIA
Last Name:KANLILAR-RUIZ
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5631
Mailing Address - Country:US
Mailing Address - Phone:310-301-8707
Mailing Address - Fax:310-301-8751
Practice Address - Street 1:200 MEDICAL PLAZA SUITE 365A
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-3026
Practice Address - Country:US
Practice Address - Phone:310-825-1597
Practice Address - Fax:310-206-0007
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-15
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA95007489363L00000X
CANP95007489363LA2100X
CA656953363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty