Provider Demographics
NPI:1265068878
Name:EGWIM, VITALIS
Entity type:Individual
Prefix:
First Name:VITALIS
Middle Name:
Last Name:EGWIM
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 1:1699 E WASHINGTON ST APT 2246
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-6460
Mailing Address - Country:US
Mailing Address - Phone:443-742-8019
Mailing Address - Fax:
Practice Address - Street 1:1699 E WASHINGTON ST APT 2246
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-6460
Practice Address - Country:US
Practice Address - Phone:443-742-8019
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-14
Last Update Date:2020-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014012363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner