Basic Information
Provider Information | |||||||||
NPI: | 1487658225 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TREVINO | ||||||||
FirstName: | VICKI | ||||||||
MiddleName: | MAREE | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | GUZMAN | ||||||||
OtherFirstName: | VICKI | ||||||||
OtherMiddleName: | MAREE | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | PA | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 1450 TREAT BLVD # 300 | ||||||||
Address2: |   | ||||||||
City: | WALNUT CREEK | ||||||||
State: | CA | ||||||||
PostalCode: | 945972168 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9259522855 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 130 LA CASA VIA # 3-211 | ||||||||
Address2: |   | ||||||||
City: | WALNUT CREEK | ||||||||
State: | CA | ||||||||
PostalCode: | 945983045 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9259330984 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/09/2005 | ||||||||
LastUpdateDate: | 10/18/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: | 06/14/2006 | ||||||||
NPIReactivationDate: | 03/29/2007 | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 10/18/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 110084 | AK | N |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   | 363A00000X | PA17774 | CA | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |   |
No ID Information.