Provider Demographics
NPI:1437891561
Name:DE VERA, JOHN MENARD CASTILLO (NP)
Entity Type:Individual
Prefix:MR
First Name:JOHN MENARD
Middle Name:CASTILLO
Last Name:DE VERA
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:26829 CUATRO MILPAS ST
Mailing Address - Street 2:
Mailing Address - City:VALENCIA
Mailing Address - State:CA
Mailing Address - Zip Code:91354-2332
Mailing Address - Country:US
Mailing Address - Phone:818-370-9062
Mailing Address - Fax:
Practice Address - Street 1:6245 DE LONGPRE AVE FL 2
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90028-8253
Practice Address - Country:US
Practice Address - Phone:323-499-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-09
Last Update Date:2022-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95020629363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty