Individual
JONATHAN WIBISONO
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
NP
Contact information
Practice address
851 E 6TH ST, SUITE B-4, BEAUMONT, CA 92223-2340
(951) 845-2294
Mailing address
851 E 6TH ST, SUITE B-4, BEAUMONT, CA 92223-2340
(951) 845-2294
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
Primary
95004343
CA
Other
Enumeration date
07/18/2016
Last updated
07/18/2016
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