Provider Demographics
NPI:1518126804
Name:BULMER, JOHANNA (PA)
Entity Type:Individual
Prefix:MRS
First Name:JOHANNA
Middle Name:
Last Name:BULMER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:JOHANNA
Other - Middle Name:
Other - Last Name:LIZAOLA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:60 WEST OLSEN RD #4300
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1220 LA VENTA DR STE 103
Practice Address - Street 2:
Practice Address - City:WESTLAKE VILLAGE
Practice Address - State:CA
Practice Address - Zip Code:91361-3748
Practice Address - Country:US
Practice Address - Phone:805-493-3225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-06-03
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19497363A00000X
CA19497363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAT884XMedicare PIN