Provider Demographics
NPI:1053466326
Name:TAPAWAN-SERRANO, MARY GRACE (MD)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:GRACE
Last Name:TAPAWAN-SERRANO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10470 OLD PLACERVILLE RD
Mailing Address - Street 2:#100
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95827-2539
Mailing Address - Country:US
Mailing Address - Phone:866-681-0736
Mailing Address - Fax:
Practice Address - Street 1:444 PLUMAS BLVD
Practice Address - Street 2:
Practice Address - City:YUBA CITY
Practice Address - State:CA
Practice Address - Zip Code:95991-5071
Practice Address - Country:US
Practice Address - Phone:530-749-3420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2015-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA82865207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A828650Medicaid
CA00A828650Medicare ID - Type Unspecified
H21298Medicare UPIN