Provider Demographics
NPI:1477286540
Name:BRONNER, NIKI ISABELLA (PA)
Entity Type:Individual
Prefix:
First Name:NIKI
Middle Name:ISABELLA
Last Name:BRONNER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5860
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST STE 2000
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5322
Practice Address - Country:US
Practice Address - Phone:323-442-5860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2023-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA63033363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty