Provider Demographics
NPI:1558991844
Name:BAJAMUNDI, KEITH WILLIAM
Entity Type:Individual
Prefix:
First Name:KEITH
Middle Name:WILLIAM
Last Name:BAJAMUNDI
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 1:7282 EL CIELO CIR
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-2612
Mailing Address - Country:US
Mailing Address - Phone:714-515-0538
Mailing Address - Fax:
Practice Address - Street 1:7282 EL CIELO CIR
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-2612
Practice Address - Country:US
Practice Address - Phone:714-515-0538
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-01-25
Last Update Date:2021-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95047739163W00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered Nurse