Healthcare Provider Details

I. General information

NPI: 1063004281
Provider Name (Legal Business Name): MARCEL ENRIQUE RAUDA PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/09/2021
Last Update Date: 04/25/2022
Certification Date: 05/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32605 TEMECULA PKWY STE 202
TEMECULA CA
92592-6838
US

IV. Provider business mailing address

748 E HOLT BLVD
ONTARIO CA
91761-1850
US

V. Phone/Fax

Practice location:
  • Phone: 858-427-5060
  • Fax:
Mailing address:
  • Phone: 818-572-3988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95016623
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: