Basic Information
Provider Information | |||||||||
NPI: | 1306276936 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DESKIN | ||||||||
FirstName: | SARA | ||||||||
MiddleName: | R | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | N.P | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | REVELLA | ||||||||
OtherFirstName: | SARA | ||||||||
OtherMiddleName: | B | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 10170 SORRENTO VALLEY RD | ||||||||
Address2: | MAIL DROP SV-5 | ||||||||
City: | SAN DIEGO | ||||||||
State: | CA | ||||||||
PostalCode: | 921211604 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8587845888 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10666 N TORREY PINES RD | ||||||||
Address2: |   | ||||||||
City: | LA JOLLA | ||||||||
State: | CA | ||||||||
PostalCode: | 920371027 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8585548920 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/18/2013 | ||||||||
LastUpdateDate: | 02/05/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 23300 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 163W00000X | 757303 | CA | N |   | Nursing Service Providers | Registered Nurse |   |
No ID Information.