Provider Demographics
NPI:1124612890
Name:MBATA, AUSTIN (LVN)
Entity type:Individual
Prefix:
First Name:AUSTIN
Middle Name:
Last Name:MBATA
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2468 KAISER WAY
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-9064
Mailing Address - Country:US
Mailing Address - Phone:925-499-7380
Mailing Address - Fax:
Practice Address - Street 1:2468 KAISER WAY
Practice Address - Street 2:
Practice Address - City:ANTIOCH
Practice Address - State:CA
Practice Address - Zip Code:94531-9064
Practice Address - Country:US
Practice Address - Phone:925-499-7380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-23
Last Update Date:2021-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01004170376K00000X
CAVN715353164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
No376K00000XNursing Service Related ProvidersNurse's Aide