Provider Demographics
NPI:1639843212
Name:HERRERA, JORGE DANIEL (AGACNP)
Entity Type:Individual
Prefix:MR
First Name:JORGE
Middle Name:DANIEL
Last Name:HERRERA
Suffix:
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:35 TEASDALE ST
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-3150
Mailing Address - Country:US
Mailing Address - Phone:310-748-9532
Mailing Address - Fax:
Practice Address - Street 1:1680 E 120TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90059-3026
Practice Address - Country:US
Practice Address - Phone:310-748-9532
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018008363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care