Provider Demographics
NPI:1760590897
Name:GALUSTIANS, NANCY JILL (PA)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:JILL
Last Name:GALUSTIANS
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8410
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91109-8410
Mailing Address - Country:US
Mailing Address - Phone:818-847-4436
Mailing Address - Fax:818-847-4432
Practice Address - Street 1:181 SOUTH BUENA VISTA STREET
Practice Address - Street 2:3RD FLOOR
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-1204
Practice Address - Country:US
Practice Address - Phone:818-847-4436
Practice Address - Fax:818-847-4432
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-28
Last Update Date:2012-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17319363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPA17319EMedicare UPIN