Healthcare Provider Details

I. General information

NPI: 1952800781
Provider Name (Legal Business Name): RENE WILFREDO REYNA-TOBAR NP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2018
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 BERCUT DR STE C
SACRAMENTO CA
95811-0110
US

IV. Provider business mailing address

5488 GRACEN WAY
SACRAMENTO CA
95835-2164
US

V. Phone/Fax

Practice location:
  • Phone: 916-441-3819
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95006656
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number95006656
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number95006656
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95006656
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95006656
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: