Basic Information
| Provider Information | |||||||||
| NPI: | 1053466326 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TAPAWAN-SERRANO | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | GRACE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10470 OLD PLACERVILLE RD | ||||||||
| Address2: | #100 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958272539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8666810736 | ||||||||
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| Practice Location | |||||||||
| Address1: | 444 PLUMAS BLVD | ||||||||
| Address2: | |||||||||
| City: | YUBA CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959915071 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5307493420 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/24/2007 | ||||||||
| LastUpdateDate: | 06/12/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A82865 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 00A828650 | 05 | CA | MEDICAID |