Provider Demographics
NPI:1891476941
Name:MIYAMOTO, BRETT KIYOSHI
Entity Type:Individual
Prefix:MR
First Name:BRETT
Middle Name:KIYOSHI
Last Name:MIYAMOTO
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 1:959 IRONSHOE CT
Mailing Address - Street 2:
Mailing Address - City:WALNUT
Mailing Address - State:CA
Mailing Address - Zip Code:91789-0909
Mailing Address - Country:US
Mailing Address - Phone:909-900-8740
Mailing Address - Fax:
Practice Address - Street 1:959 IRONSHOE CT
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-0909
Practice Address - Country:US
Practice Address - Phone:909-900-8740
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-31
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95168544163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse