Provider Demographics
NPI:1922582832
Name:HADILAKSONO, ANNA JADWIGA (NP)
Entity Type:Individual
Prefix:
First Name:ANNA
Middle Name:JADWIGA
Last Name:HADILAKSONO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 LA COLIMA
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-2841
Mailing Address - Country:US
Mailing Address - Phone:732-754-3197
Mailing Address - Fax:
Practice Address - Street 1:135 CARMEN LN
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93458-7729
Practice Address - Country:US
Practice Address - Phone:805-928-7361
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-18
Last Update Date:2018-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010045363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care