Healthcare Provider Details

I. General information

NPI: 1316008972
Provider Name (Legal Business Name): DIEGO H SEVILLA PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

436 S RIVERSIDE AVE
RIALTO CA
92376-6523
US

IV. Provider business mailing address

436 S RIVERSIDE AVE
RIALTO CA
92376-6523
US

V. Phone/Fax

Practice location:
  • Phone: 909-877-8868
  • Fax: 909-877-0008
Mailing address:
  • Phone: 909-877-8868
  • Fax: 909-877-0008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13946
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: