Provider Demographics
NPI:1700340403
Name:RIOS, WILFREDO
Entity Type:Individual
Prefix:
First Name:WILFREDO
Middle Name:
Last Name:RIOS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:WILFREDO
Other - Middle Name:JOSE
Other - Last Name:RIOS
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:742 W GARDENA BLVD
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-5024
Mailing Address - Country:US
Mailing Address - Phone:310-392-8636
Mailing Address - Fax:
Practice Address - Street 1:742 W GARDENA BLVD
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-5024
Practice Address - Country:US
Practice Address - Phone:310-392-8636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-27
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95010804363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily