Provider Demographics
NPI:1871032870
Name:SETIAWAN, EUGENIE LEI (MSN, AGACNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:EUGENIE
Middle Name:LEI
Last Name:SETIAWAN
Suffix:
Gender:F
Credentials:MSN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6446 SEAMAN ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-2628
Mailing Address - Country:US
Mailing Address - Phone:919-265-7024
Mailing Address - Fax:
Practice Address - Street 1:10990 SAN DIEGO MISSION RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-2417
Practice Address - Country:US
Practice Address - Phone:919-265-7024
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-02-23
Last Update Date:2020-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95103007163W00000X
CA95005910363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse