Provider Demographics
NPI:1700207388
Name:TEOXON, LUIS SERVANO (NP-C)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:SERVANO
Last Name:TEOXON
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3420 COUNCIL ST APT 102
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90004-3629
Mailing Address - Country:US
Mailing Address - Phone:213-386-0654
Mailing Address - Fax:
Practice Address - Street 1:11750 STERLING AVE STE C
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92503
Practice Address - Country:US
Practice Address - Phone:951-637-8752
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-26
Last Update Date:2013-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22969364SF0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SF0001XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistFamily Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXF1212085OtherAANP CERTIFICATION