Provider Demographics
NPI:1093407306
Name:SEVILLA, JOHN
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:SEVILLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JOHN MARIE
Other - Middle Name:DATU
Other - Last Name:SEVILLA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:11 WAVERLY CT
Mailing Address - Street 2:
Mailing Address - City:SOUTH SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94080-5556
Mailing Address - Country:US
Mailing Address - Phone:650-303-1860
Mailing Address - Fax:
Practice Address - Street 1:11 WAVERLY CT
Practice Address - Street 2:
Practice Address - City:SOUTH SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94080-5556
Practice Address - Country:US
Practice Address - Phone:650-303-1860
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-24
Last Update Date:2023-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95024275363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty