Basic Information
| Provider Information | |||||||||
| NPI: | 1790258788 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PETERMAN | ||||||||
| FirstName: | KYLIE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 23961 CALLE DE LA MAGDALENA STE 504 | ||||||||
| Address2: | |||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926533665 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9495885800 | ||||||||
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| Practice Location | |||||||||
| Address1: | 23181 VERDUGO DR STE 103A | ||||||||
| Address2: | |||||||||
| City: | LAGUNA HILLS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926531313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9493661053 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2019 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 56343 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.