Provider Demographics
NPI:1669738167
Name:NIEVERA, PATRICK P
Entity type:Individual
Prefix:MR
First Name:PATRICK
Middle Name:P
Last Name:NIEVERA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1016 N ORANGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90046-6127
Mailing Address - Country:US
Mailing Address - Phone:626-318-8036
Mailing Address - Fax:
Practice Address - Street 1:1016 N ORANGE GROVE AVE
Practice Address - Street 2:
Practice Address - City:WEST HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90046-6127
Practice Address - Country:US
Practice Address - Phone:626-318-8036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-09
Last Update Date:2012-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA37730225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA37730Medicaid
CA37730Medicare PIN