Provider Demographics
NPI:1972187482
Name:FUYANA, EDVINA SAMKELISO
Entity Type:Individual
Prefix:
First Name:EDVINA
Middle Name:SAMKELISO
Last Name:FUYANA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17981 SKY PARK CIR BLDG 39
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92614-6309
Mailing Address - Country:US
Mailing Address - Phone:877-896-7350
Mailing Address - Fax:
Practice Address - Street 1:17981 SKY PARK CIR BLDG 39
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92614-6309
Practice Address - Country:US
Practice Address - Phone:877-896-7350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-11
Last Update Date:2022-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95017106207QA0505X
GA213866363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine