Provider Demographics
NPI:1780958330
Name:PERUN, ROSELOU R (NP)
Entity type:Individual
Prefix:
First Name:ROSELOU
Middle Name:R
Last Name:PERUN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:127 PAMELA RD
Mailing Address - Street 2:
Mailing Address - City:MONROVIA
Mailing Address - State:CA
Mailing Address - Zip Code:91016-5034
Mailing Address - Country:US
Mailing Address - Phone:323-708-9198
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST STE 3000
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5315
Practice Address - Country:US
Practice Address - Phone:323-442-8545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-29
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA21190363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902846306OtherGROUP NPI
CAGR0100430OtherGROUP MEDI-CAL
CAW18762OtherGROUP MEDICARE