Provider Demographics
NPI:1053486944
Name:NINO, EDWARD BURGOS (NP)
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:BURGOS
Last Name:NINO
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 1:11080 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90064-1937
Mailing Address - Country:US
Mailing Address - Phone:310-913-4310
Mailing Address - Fax:
Practice Address - Street 1:11080 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90064-1937
Practice Address - Country:US
Practice Address - Phone:310-913-4310
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2025-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP #14333363LF0000X
CANP14333363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWNP14333AOtherPPIN
CAQ50144Medicare UPIN