Basic Information
| Provider Information | |||||||||
| NPI: | 1013278704 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | AYSON | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | MAE KETRING | ||||||||
| NamePrefix: | |||||||||
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| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | KETRING | ||||||||
| OtherFirstName: | NICOLE | ||||||||
| OtherMiddleName: | MAE | ||||||||
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| OtherCredential: | M.D. | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3020 CHILDRENS WAY | ||||||||
| Address2: | MC 5003 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583096300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3665 KEARNY VILLA RD STE 501 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921231953 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665803 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/30/2012 | ||||||||
| LastUpdateDate: | 09/20/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | A128091 | CA | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.