Provider Demographics
NPI:1366131591
Name:DE VERA, NATHALIE MARIE (PA-C)
Entity type:Individual
Prefix:
First Name:NATHALIE
Middle Name:MARIE
Last Name:DE VERA
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1211 N BROADWAY
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92701-3411
Mailing Address - Country:US
Mailing Address - Phone:714-767-6182
Mailing Address - Fax:
Practice Address - Street 1:113 WATERWORKS WAY
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-3167
Practice Address - Country:US
Practice Address - Phone:949-551-1113
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-03
Last Update Date:2025-02-19
Deactivation Date:2023-12-13
Deactivation Code:
Reactivation Date:2023-12-19
Provider Licenses
StateLicense IDTaxonomies
CA363A00000X
CAPA63686363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant