Provider Demographics
NPI:1093561904
Name:SAMEDRA, RICHARD GABRIEL (PMHNP-BC)
Entity type:Individual
Prefix:MR
First Name:RICHARD
Middle Name:GABRIEL
Last Name:SAMEDRA
Suffix:
Gender:
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:123 ORANGE GROVE AVE
Mailing Address - Street 2:
Mailing Address - City:PLACENTIA
Mailing Address - State:CA
Mailing Address - Zip Code:92870-4848
Mailing Address - Country:US
Mailing Address - Phone:949-566-4308
Mailing Address - Fax:714-683-1473
Practice Address - Street 1:1720 W BALL RD STE 4C
Practice Address - Street 2:
Practice Address - City:ANAHEIM
Practice Address - State:CA
Practice Address - Zip Code:92804-5591
Practice Address - Country:US
Practice Address - Phone:714-683-1472
Practice Address - Fax:714-683-1473
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-30
Last Update Date:2025-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030301363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty