Provider Demographics
NPI:1659981330
Name:BAJWA, KAMALJOT
Entity Type:Individual
Prefix:
First Name:KAMALJOT
Middle Name:
Last Name:BAJWA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2404 VAN DER GOES WAY
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95356-0488
Mailing Address - Country:US
Mailing Address - Phone:209-604-8398
Mailing Address - Fax:
Practice Address - Street 1:7707 AUSTIN RD
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95215-8312
Practice Address - Country:US
Practice Address - Phone:209-467-1321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-06
Last Update Date:2020-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015081363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health