Provider Demographics
NPI:1730380221
Name:ESTRADA-BAZAN, YVONNE DIANE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:YVONNE
Middle Name:DIANE
Last Name:ESTRADA-BAZAN
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:12450 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:PACOIMA
Mailing Address - State:CA
Mailing Address - Zip Code:91331-1391
Mailing Address - Country:US
Mailing Address - Phone:818-896-1161
Mailing Address - Fax:818-896-5069
Practice Address - Street 1:12450 VAN NUYS BLVD
Practice Address - Street 2:SUITE 200
Practice Address - City:PACOIMA
Practice Address - State:CA
Practice Address - Zip Code:91331-1391
Practice Address - Country:US
Practice Address - Phone:818-896-1161
Practice Address - Fax:818-896-5069
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2015-05-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA12938363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6758Medicaid
CA7068Medicaid
CA7420Medicaid
Q16389Medicare UPIN