Basic Information
| Provider Information | |||||||||
| NPI: | 1942808811 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MARAVILLA | ||||||||
| FirstName: | NELSON | ||||||||
| MiddleName: | JAVIER | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 65792 ESTRELLA AVE | ||||||||
| Address2: | |||||||||
| City: | DESERT HOT SPRINGS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922403514 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608800408 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4445 MAGNOLIA AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925014135 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9517883000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2020 | ||||||||
| LastUpdateDate: | 10/13/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 95001423 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.