Provider Demographics
NPI:1689221483
Name:VALLE MARISCAL, REYNA LUCERO
Entity Type:Individual
Prefix:
First Name:REYNA
Middle Name:LUCERO
Last Name:VALLE MARISCAL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1505 RIDLON LN
Mailing Address - Street 2:
Mailing Address - City:CERES
Mailing Address - State:CA
Mailing Address - Zip Code:95307-9360
Mailing Address - Country:US
Mailing Address - Phone:209-496-8869
Mailing Address - Fax:
Practice Address - Street 1:1505 RIDLON LN
Practice Address - Street 2:
Practice Address - City:CERES
Practice Address - State:CA
Practice Address - Zip Code:95307-9360
Practice Address - Country:US
Practice Address - Phone:209-496-8869
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant