Healthcare Provider Details

I. General information

NPI: 1093407306
Provider Name (Legal Business Name): JOHN SEVILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JOHN MARIE DATU SEVILLA

II. Dates (important events)

Enumeration Date: 05/24/2023
Last Update Date: 05/24/2023
Certification Date: 05/24/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 WAVERLY CT
SOUTH SAN FRANCISCO CA
94080-5556
US

IV. Provider business mailing address

11 WAVERLY CT
SOUTH SAN FRANCISCO CA
94080-5556
US

V. Phone/Fax

Practice location:
  • Phone: 650-303-1860
  • Fax:
Mailing address:
  • Phone: 650-303-1860
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP95024275
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: