Provider Demographics
NPI:1275052805
Name:SEVIDAL, MARIA ROSE (NP)
Entity Type:Individual
Prefix:
First Name:MARIA ROSE
Middle Name:
Last Name:SEVIDAL
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MARIA ROSE
Other - Middle Name:
Other - Last Name:MIRANDA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:209 S 28TH ST
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-7415
Mailing Address - Country:US
Mailing Address - Phone:530-604-8022
Mailing Address - Fax:530-241-1174
Practice Address - Street 1:209 S 28TH ST
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-7415
Practice Address - Country:US
Practice Address - Phone:530-604-8022
Practice Address - Fax:530-241-1174
Is Sole Proprietor?:No
Enumeration Date:2017-09-14
Last Update Date:2021-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00738900363LG0600X
TX1034526363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology