Basic Information
| Provider Information | |||||||||
| NPI: | 1366954620 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KC | ||||||||
| FirstName: | BASANTA | ||||||||
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| Credential: | NURSE PRACTITIONER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 16143 WOODBRIER DR | ||||||||
| Address2: | |||||||||
| City: | WHITTIER | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906043764 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6268933700 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2101 ROSECRANS AVE # 3230 | ||||||||
| Address2: | |||||||||
| City: | EL SEGUNDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902454749 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236288671 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2017 | ||||||||
| LastUpdateDate: | 10/24/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 95006273 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.