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3930 4th Ave Ste 300 San Diego CA 92103-3119 | |
| (619) 320-8711 | |
| (619) 393-0818 |
| Full Name | |
|---|---|
| Speciality | Nurse Practitioner |
| Location | 3930 4th Ave Ste 300, San Diego, California |
| Authorized Official Name and Position | Bryan Amaro (CFO) |
| Authorized Official Contact | 5594718091 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
3930 4th Ave Ste 300 San Diego CA 92103-3119 Ph: (619) 320-8711 | 3930 4th Ave Ste 300 San Diego CA 92103-3119 Ph: (619) 320-8711 |
| NPI Number | 1972221794 |
|---|---|
| Provider Enumeration Date | 08/17/2022 |
| Last Update Date | 05/05/2023 |
| Certification Date | 05/05/2023 |
| Medicare PECOS PAC ID | 8022494178 |
|---|---|
| Medicare Enrollment ID | O20220927003933 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1972221794 | NPI | - | NPPES |
| Provider Name | Deomel M Soriano |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1164641650 PECOS PAC ID: 1153688205 Enrollment ID: I20171128003574 |
| Provider Name | Ryan M Bolt |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1639679822 PECOS PAC ID: 7113273558 Enrollment ID: I20180627002420 |
| Provider Name | Mark Patrick Manning |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1417439647 PECOS PAC ID: 0749528107 Enrollment ID: I20190208002358 |
| Provider Name | Bryan Robert Amaro |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1306564091 PECOS PAC ID: 9931585080 Enrollment ID: I20221012000919 |
| Provider Name | Lindsay Poole |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1336927623 PECOS PAC ID: 1153779186 Enrollment ID: I20231130002513 |
| Provider Name | Marissa Lynn Dvorscak |
|---|---|
| Provider Type | Practitioner - Marriage And Family Therapist |
| Provider Identifiers | NPI Number: 1699102533 PECOS PAC ID: 7911357090 Enrollment ID: I20240102002901 |
| Provider Name | Meredith Serbanica Kazato |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1598493694 PECOS PAC ID: 7517331481 Enrollment ID: I20240319003135 |
| Provider Name | Shadette Oljol Soriano |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1467712752 PECOS PAC ID: 1557806528 Enrollment ID: I20240715000970 |
| Provider Name | Ajay Kumra |
|---|---|
| Provider Type | Practitioner - Nurse Practitioner |
| Provider Identifiers | NPI Number: 1902385644 PECOS PAC ID: 3577098086 Enrollment ID: I20241120003890 |
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