Healthcare Provider Details

I. General information

NPI: 1508065764
Provider Name (Legal Business Name): ELVIS R. SIERRA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/17/2007
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6501 MECHANICSVILLE TPKE STE G1
MECHANICSVILLE VA
23111-3698
US

IV. Provider business mailing address

8005 CREIGHTON PKWY SUITE C, #132
MECHANICSVILLE VA
23111-4594
US

V. Phone/Fax

Practice location:
  • Phone: 804-522-1501
  • Fax: 804-522-1502
Mailing address:
  • Phone: 804-522-1501
  • Fax: 804-522-1502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0110002708
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: