Provider Demographics
NPI:1316008972
Name:SEVILLA, DIEGO H (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:MR
First Name:DIEGO
Middle Name:H
Last Name:SEVILLA
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:436 S RIVERSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-6523
Mailing Address - Country:US
Mailing Address - Phone:909-877-8868
Mailing Address - Fax:909-877-0008
Practice Address - Street 1:436 S RIVERSIDE AVE
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-6523
Practice Address - Country:US
Practice Address - Phone:909-877-8868
Practice Address - Fax:909-877-0008
Is Sole Proprietor?:No
Enumeration Date:2006-12-13
Last Update Date:2015-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13946363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0083640/GR0083641OtherMEDICAL GROUP
CAPA13946OtherDHS MEDICAL
CAZZZ19972Z /ZZZ20075ZOtherMEDICARE GROUP
CA0PA139461Medicare PIN
CAPA13946OtherDHS MEDICAL