Healthcare Provider Details

I. General information

NPI: 1366131591
Provider Name (Legal Business Name): NATHALIE MARIE DE VERA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2023
Last Update Date: 03/25/2026
Certification Date: 03/25/2026
Deactivation Date: 12/13/2023
Reactivation Date: 12/19/2023

III. Provider practice location address

5 HUTTON CENTRE DR STE 950
SANTA ANA CA
92707-8744
US

IV. Provider business mailing address

5 HUTTON CENTRE DR STE 950
SANTA ANA CA
92707-8744
US

V. Phone/Fax

Practice location:
  • Phone: 445-274-4233
  • Fax:
Mailing address:
  • Phone: 445-274-4233
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA63686
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: