Provider Demographics
NPI:1366131500
Name:SEVILLANA, BRYAN PINCA
Entity type:Individual
Prefix:
First Name:BRYAN
Middle Name:PINCA
Last Name:SEVILLANA
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 1:1551 E WRIGHT CIR APT 350
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92806-6842
Mailing Address - Country:US
Mailing Address - Phone:949-293-0844
Mailing Address - Fax:
Practice Address - Street 1:8615 KNOTT AVE STE 3
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-3886
Practice Address - Country:US
Practice Address - Phone:714-527-4833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-03
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018812363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily