Provider Demographics
NPI:1124804935
Name:KASONDRA, PUJA MANSUKH
Entity type:Individual
Prefix:
First Name:PUJA
Middle Name:MANSUKH
Last Name:KASONDRA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:22023 LANARK ST
Mailing Address - Street 2:
Mailing Address - City:CANOGA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91304-3834
Mailing Address - Country:US
Mailing Address - Phone:818-917-0586
Mailing Address - Fax:
Practice Address - Street 1:22023 LANARK ST
Practice Address - Street 2:
Practice Address - City:CANOGA PARK
Practice Address - State:CA
Practice Address - Zip Code:91304-3834
Practice Address - Country:US
Practice Address - Phone:818-917-0586
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-06
Last Update Date:2023-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027026363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily