Provider Demographics
NPI:1942808811
Name:MARAVILLA, NELSON JAVIER (CRNA)
Entity Type:Individual
Prefix:
First Name:NELSON
Middle Name:JAVIER
Last Name:MARAVILLA
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:65792 ESTRELLA AVE
Mailing Address - Street 2:
Mailing Address - City:DESERT HOT SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92240-3514
Mailing Address - Country:US
Mailing Address - Phone:760-880-0408
Mailing Address - Fax:
Practice Address - Street 1:4445 MAGNOLIA AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-4135
Practice Address - Country:US
Practice Address - Phone:951-788-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-13
Last Update Date:2020-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001423367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered