Provider Demographics
NPI:1710549068
Name:KURNIAWAN, BRANDON
Entity Type:Individual
Prefix:
First Name:BRANDON
Middle Name:
Last Name:KURNIAWAN
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 1:5800 HELLMAN AVE
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-2124
Mailing Address - Country:US
Mailing Address - Phone:909-367-6018
Mailing Address - Fax:
Practice Address - Street 1:11301 WILSHIRE BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90073-1003
Practice Address - Country:US
Practice Address - Phone:310-478-3711
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-07
Last Update Date:2019-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program