Provider Demographics
NPI:1811268725
Name:WATANABE, REIKO (NP)
Entity type:Individual
Prefix:
First Name:REIKO
Middle Name:
Last Name:WATANABE
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 1:200 UCLA MEDICAL PLZ
Mailing Address - Street 2:STE 550
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90095-8344
Mailing Address - Country:US
Mailing Address - Phone:310-794-7074
Mailing Address - Fax:
Practice Address - Street 1:200 UCLA MEDICAL PLZ
Practice Address - Street 2:STE 550
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90095-8344
Practice Address - Country:US
Practice Address - Phone:310-794-7074
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-24
Last Update Date:2012-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN 694572163W00000X
CANP 21175363L00000X
CAA0811043363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGC719ZMedicare PIN