Provider Demographics
NPI:1518219385
Name:OSORIO, DWIGHT ANDREW NGO
Entity Type:Individual
Prefix:
First Name:DWIGHT ANDREW
Middle Name:NGO
Last Name:OSORIO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 W ROUTE 66
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-6207
Mailing Address - Country:US
Mailing Address - Phone:626-852-5000
Mailing Address - Fax:626-852-5084
Practice Address - Street 1:150 W ROUTE 66
Practice Address - Street 2:
Practice Address - City:GLENDORA
Practice Address - State:CA
Practice Address - Zip Code:91740-6207
Practice Address - Country:US
Practice Address - Phone:626-852-5000
Practice Address - Fax:626-852-5084
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2024-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95049760163WP0808X, 163WP0808X
CA245283164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No164X00000XNursing Service ProvidersLicensed Vocational Nurse