Provider Demographics
NPI:1831872357
Name:GRIJALVA, WILIAN
Entity type:Individual
Prefix:
First Name:WILIAN
Middle Name:
Last Name:GRIJALVA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5459 MERIDIAN PL
Mailing Address - Street 2:
Mailing Address - City:BONSALL
Mailing Address - State:CA
Mailing Address - Zip Code:92003-3739
Mailing Address - Country:US
Mailing Address - Phone:949-547-0486
Mailing Address - Fax:
Practice Address - Street 1:5459 MERIDIAN PL
Practice Address - Street 2:
Practice Address - City:BONSALL
Practice Address - State:CA
Practice Address - Zip Code:92003-3739
Practice Address - Country:US
Practice Address - Phone:949-547-0486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-10
Last Update Date:2023-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95026675363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily