Provider Demographics
NPI:1124897046
Name:SURYANATA, JUSAC ARIZTHIAN (NP)
Entity type:Individual
Prefix:
First Name:JUSAC
Middle Name:ARIZTHIAN
Last Name:SURYANATA
Suffix:
Gender:
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3308 CAROLYN CIR
Mailing Address - Street 2:
Mailing Address - City:OCEANSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92054-3844
Mailing Address - Country:US
Mailing Address - Phone:760-658-4405
Mailing Address - Fax:
Practice Address - Street 1:3308 CAROLYN CIR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92054-3844
Practice Address - Country:US
Practice Address - Phone:760-658-4405
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-20
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95166131163WP0808X
CA95031637363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95166131OtherCALIFORNIA BRN
CA95031637OtherCALIFORNIA BRN