Provider Demographics
NPI:1952860595
Name:OSSA, ANDREW ROGER (RDN)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:ROGER
Last Name:OSSA
Suffix:
Gender:M
Credentials:RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19979 MODOC RD
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308-6134
Mailing Address - Country:US
Mailing Address - Phone:562-713-4615
Mailing Address - Fax:
Practice Address - Street 1:18300 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2206
Practice Address - Country:US
Practice Address - Phone:562-713-4615
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-13
Last Update Date:2020-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA86098381133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered