Provider Demographics
NPI:1942857834
Name:ATANESIAN, VARDAN (AGPCNP)
Entity Type:Individual
Prefix:
First Name:VARDAN
Middle Name:
Last Name:ATANESIAN
Suffix:
Gender:M
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12881 RIMMON RD
Mailing Address - Street 2:
Mailing Address - City:EASTVALE
Mailing Address - State:CA
Mailing Address - Zip Code:92880-3438
Mailing Address - Country:US
Mailing Address - Phone:951-496-2952
Mailing Address - Fax:
Practice Address - Street 1:4445 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4135
Practice Address - Country:US
Practice Address - Phone:951-788-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-24
Last Update Date:2019-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011998363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health