Provider Demographics
NPI:1770303323
Name:MAURO, TIVI (PAC)
Entity type:Individual
Prefix:
First Name:TIVI
Middle Name:
Last Name:MAURO
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 INGRAHAM ST APT 14-104
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92109-5906
Mailing Address - Country:US
Mailing Address - Phone:716-573-6333
Mailing Address - Fax:
Practice Address - Street 1:3910 INGRAHAM ST APT 14-104
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92109-5906
Practice Address - Country:US
Practice Address - Phone:716-573-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-16
Last Update Date:2024-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA65136363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant