Provider Demographics
NPI:1396432399
Name:SUDIRO, TRYSARI
Entity type:Individual
Prefix:
First Name:TRYSARI
Middle Name:
Last Name:SUDIRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:TRYSARI
Other - Middle Name:
Other - Last Name:CHANDRA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2810 LONG BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-1558
Mailing Address - Country:US
Mailing Address - Phone:626-709-7802
Mailing Address - Fax:
Practice Address - Street 1:2810 LONG BEACH BLVD
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1558
Practice Address - Country:US
Practice Address - Phone:626-709-7802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-19
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018240363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care