Provider Demographics
NPI:1528015849
Name:MITU, BRIAN PAUL (FNP, PA-C)
Entity Type:Individual
Prefix:MR
First Name:BRIAN
Middle Name:PAUL
Last Name:MITU
Suffix:
Gender:M
Credentials:FNP, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2803 GRAMERCY AVE
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90501-5431
Mailing Address - Country:US
Mailing Address - Phone:310-869-1218
Mailing Address - Fax:
Practice Address - Street 1:29409 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:RANCHO PALOS VERDES
Practice Address - State:CA
Practice Address - Zip Code:90275-1137
Practice Address - Country:US
Practice Address - Phone:310-891-6684
Practice Address - Fax:310-514-4903
Is Sole Proprietor?:No
Enumeration Date:2006-05-30
Last Update Date:2024-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA18341363A00000X
CA16318363LF0000X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA18341OtherPA-C LICENSE NUMBER
CA16318OtherFNP LICENSE NUMBER