Provider Demographics
NPI:1548565740
Name:WILBORN, ASHA JENISE (NP)
Entity Type:Individual
Prefix:
First Name:ASHA
Middle Name:JENISE
Last Name:WILBORN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 PARK PLAZA DRIVE STE 150
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703
Mailing Address - Country:US
Mailing Address - Phone:562-282-4027
Mailing Address - Fax:
Practice Address - Street 1:1310 W STEWART DR STE 410
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3855
Practice Address - Country:US
Practice Address - Phone:714-639-9401
Practice Address - Fax:714-639-4105
Is Sole Proprietor?:No
Enumeration Date:2011-01-19
Last Update Date:2018-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA625834163W00000X
CA20529363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA20529OtherNURSE PRACTITIONER LICENSE NUMBER
CA69334OtherPUBLIC HEALTH NURSE LICENSE NUMBER
CAP01064753OtherRAILROAD MEDICARE
CA625834OtherRN LICENSE NUMBER
1912919804OtherTYPE 2 NPI
CAER023ZMedicare PIN
CAW1514Medicare PIN