Provider Demographics
NPI:1992148092
Name:TANIG-SANJONGCO, EDITHA (FNP-BC)
Entity type:Individual
Prefix:
First Name:EDITHA
Middle Name:
Last Name:TANIG-SANJONGCO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:EDITHA
Other - Middle Name:C
Other - Last Name:TANIG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:19066 MAGNOLIA STREET
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92646
Mailing Address - Country:US
Mailing Address - Phone:714-968-0068
Mailing Address - Fax:714-964-8051
Practice Address - Street 1:661 W 1ST ST
Practice Address - Street 2:SUITE G
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-2939
Practice Address - Country:US
Practice Address - Phone:714-665-9890
Practice Address - Fax:714-665-9891
Is Sole Proprietor?:No
Enumeration Date:2013-04-09
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22959363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
1992148092Medicare PIN