Provider Demographics
NPI:1043036429
Name:BADUA, PETER PAUL MUTYA
Entity type:Individual
Prefix:MR
First Name:PETER PAUL
Middle Name:MUTYA
Last Name:BADUA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:316 VIA NAPOLI
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-4189
Mailing Address - Country:US
Mailing Address - Phone:818-519-5373
Mailing Address - Fax:
Practice Address - Street 1:10621 CHURCH ST STE 120
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-6834
Practice Address - Country:US
Practice Address - Phone:909-944-0486
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030226363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty