Healthcare Provider Details

I. General information

NPI: 1790413920
Provider Name (Legal Business Name): DAVID MENDIOLA BASCO III NURSE PRACTITIONER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2022
Last Update Date: 05/24/2023
Certification Date: 05/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3301 C ST STE 1500
SACRAMENTO CA
95816-3371
US

IV. Provider business mailing address

4800 Y STREET SUITE 3740
SACRAMENTO CA
95817
US

V. Phone/Fax

Practice location:
  • Phone: 916-734-7463
  • Fax: 916-734-6493
Mailing address:
  • Phone: 916-734-3658
  • Fax: 916-703-5368

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberF07221391
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95022230
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number802458
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: