Provider Demographics
NPI:1740246982
Name:CARLOS, JEAN NEPOMUCENO (NP)
Entity type:Individual
Prefix:MRS
First Name:JEAN
Middle Name:NEPOMUCENO
Last Name:CARLOS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:JEAN
Other - Middle Name:
Other - Last Name:NEPOMUCENO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NP
Mailing Address - Street 1:415 OLD NEWPORT BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-4248
Mailing Address - Country:US
Mailing Address - Phone:949-548-9611
Mailing Address - Fax:949-548-9958
Practice Address - Street 1:415 OLD NEWPORT BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4248
Practice Address - Country:US
Practice Address - Phone:949-548-9611
Practice Address - Fax:949-548-9958
Is Sole Proprietor?:No
Enumeration Date:2006-04-25
Last Update Date:2010-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP15130363LA2100X
CARN570100163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine