Provider Demographics
NPI:1386127355
Name:MENJO, KEISUKE (NP-C)
Entity type:Individual
Prefix:MR
First Name:KEISUKE
Middle Name:
Last Name:MENJO
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12900 PARK PLAZA DR # 3150
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-9329
Mailing Address - Country:US
Mailing Address - Phone:562-622-2800
Mailing Address - Fax:714-741-4479
Practice Address - Street 1:12898 TOWNE CENTER DR
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-8546
Practice Address - Country:US
Practice Address - Phone:562-622-2800
Practice Address - Fax:562-741-4479
Is Sole Proprietor?:No
Enumeration Date:2018-09-14
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAG08180103363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology