Provider Demographics
NPI:1023644556
Name:HOME CARE MD MEDICAL GROUP
Entity type:Organization
Organization Name:HOME CARE MD MEDICAL GROUP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:SHYLEE
Authorized Official - Middle Name:BAUTISTA
Authorized Official - Last Name:TIAMSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:310-292-0117
Mailing Address - Street 1:100 N BARRANCA ST # 900-J
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-1637
Mailing Address - Country:US
Mailing Address - Phone:626-377-7608
Mailing Address - Fax:626-206-0553
Practice Address - Street 1:100 N BARRANCA ST # 900-J
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-1637
Practice Address - Country:US
Practice Address - Phone:626-377-7608
Practice Address - Fax:626-206-0553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-16
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2083X0100XAllopathic & Osteopathic PhysiciansPreventive MedicineOccupational MedicineGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty