Provider Demographics
NPI:1700312295
Name:O'BRIEN, IAN (AGNP-BC)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:
Last Name:O'BRIEN
Suffix:
Gender:M
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12026 HOFFMAN ST UNIT 101
Mailing Address - Street 2:
Mailing Address - City:STUDIO CITY
Mailing Address - State:CA
Mailing Address - Zip Code:91604-4726
Mailing Address - Country:US
Mailing Address - Phone:321-223-8361
Mailing Address - Fax:
Practice Address - Street 1:5757 PLAZA DR
Practice Address - Street 2:
Practice Address - City:CYPRESS
Practice Address - State:CA
Practice Address - Zip Code:90630-5000
Practice Address - Country:US
Practice Address - Phone:407-335-8226
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-03
Last Update Date:2021-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11002144363LA2200X
COAPN.0992960-NP363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health