Provider Demographics
NPI:1508632480
Name:FONSECA, ANDRES (NP)
Entity Type:Individual
Prefix:
First Name:ANDRES
Middle Name:
Last Name:FONSECA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13069 MONTFORD ST
Mailing Address - Street 2:
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1818
Mailing Address - Country:US
Mailing Address - Phone:949-517-8566
Mailing Address - Fax:
Practice Address - Street 1:4305 TORRANCE BLVD STE 106
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-4400
Practice Address - Country:US
Practice Address - Phone:310-542-9758
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-30
Last Update Date:2023-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028098363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily