Provider Demographics
NPI:1487658225
Name:TREVINO, VICKI MAREE (PA)
Entity Type:Individual
Prefix:MS
First Name:VICKI
Middle Name:MAREE
Last Name:TREVINO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MS
Other - First Name:VICKI
Other - Middle Name:MAREE
Other - Last Name:GUZMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:1450 TREAT BLVD # 300
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94597-2168
Mailing Address - Country:US
Mailing Address - Phone:925-952-2855
Mailing Address - Fax:
Practice Address - Street 1:130 LA CASA VIA # 3-211
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-3045
Practice Address - Country:US
Practice Address - Phone:925-933-0984
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2021-10-18
Deactivation Date:2006-06-14
Deactivation Code:
Reactivation Date:2007-03-29
Provider Licenses
StateLicense IDTaxonomies
AK110084363A00000X
CAPA17774363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant