Basic Information
| Provider Information | |||||||||
| NPI: | 1174785489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | NICORA BIA | ||||||||
| FirstName: | MARIA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | NICORA-GARRETT | ||||||||
| OtherFirstName: | MARIA | ||||||||
| OtherMiddleName: | M | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 2965 EAST ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960073481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303780486 | ||||||||
| FaxNumber: | 5303780582 | ||||||||
| Practice Location | |||||||||
| Address1: | 2965 EAST ST | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960073481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5303780486 | ||||||||
| FaxNumber: | 5307229999 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 02/08/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A108375 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | GR0089252 | 05 | CA | MEDICAID | RHM53957F | 05 | CA | MEDICAID | 553957 | 01 | CA | MEDICARE ID-TYPE UNSPECIFIED | OTHER |