Provider Demographics
NPI:1467590158
Name:PROVENCIO, AUGIE N
Entity Type:Individual
Prefix:
First Name:AUGIE
Middle Name:N
Last Name:PROVENCIO
Suffix:
Gender:M
Credentials:
Other - Prefix:DR
Other - First Name:AUGUSTINE
Other - Middle Name:QUINONES
Other - Last Name:PROVENCIO
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:600 B ST BLDG A-C
Mailing Address - Street 2:
Mailing Address - City:LIVINGSTON
Mailing Address - State:CA
Mailing Address - Zip Code:95334-9593
Mailing Address - Country:US
Mailing Address - Phone:209-850-3500
Mailing Address - Fax:
Practice Address - Street 1:600 B ST BLDG A-C
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:CA
Practice Address - Zip Code:95334-9593
Practice Address - Country:US
Practice Address - Phone:209-850-3500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-02
Last Update Date:2022-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ36333207Q00000X
AK3673207Q00000X
CAA48099207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A480990Medicaid
AZ539497Medicaid
CA00A480990Medicaid
AZH60175Medicare UPIN
AZ8HZG37Medicare PIN
AZ539497Medicaid