Provider Demographics
NPI:1750077384
Name:RIESER, GAVIN DE JULIO (RN)
Entity type:Individual
Prefix:
First Name:GAVIN
Middle Name:DE JULIO
Last Name:RIESER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6180 AGEE ST UNIT 173
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92122-3615
Mailing Address - Country:US
Mailing Address - Phone:916-396-8095
Mailing Address - Fax:
Practice Address - Street 1:3780 MASSACHUSETTS AVE
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-7638
Practice Address - Country:US
Practice Address - Phone:619-465-1313
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-17
Last Update Date:2023-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95263200163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse