Basic Information
| Provider Information | |||||||||
| NPI: | 1053486944 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NINO | ||||||||
| FirstName: | EDWARD | ||||||||
| MiddleName: | BURGOS | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1436 GOODRICH BLVD | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900225111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237251337 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1436 GOODRICH BLVD | ||||||||
| Address2: | |||||||||
| City: | COMMERCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900225111 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3237251337 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/24/2006 | ||||||||
| LastUpdateDate: | 12/14/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | NP #14333 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363LP0808X | NP14333 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | WNP14333A | 01 | CA | PPIN | OTHER |