Provider Demographics
NPI:1790094928
Name:SHISTICK, RONALD (FNP)
Entity Type:Individual
Prefix:
First Name:RONALD
Middle Name:
Last Name:SHISTICK
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7847 VALLEY FLORES DR
Mailing Address - Street 2:
Mailing Address - City:WEST HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91304-6105
Mailing Address - Country:US
Mailing Address - Phone:818-992-1502
Mailing Address - Fax:
Practice Address - Street 1:7847 VALLEY FLORES DR
Practice Address - Street 2:
Practice Address - City:WEST HILLS
Practice Address - State:CA
Practice Address - Zip Code:91304-6105
Practice Address - Country:US
Practice Address - Phone:818-992-1502
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-05
Last Update Date:2011-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA19641363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4444167333Medicaid
CA4444167333Medicaid