Provider Demographics
NPI:1215691118
Name:PROVENCIO, CELINA
Entity type:Individual
Prefix:
First Name:CELINA
Middle Name:
Last Name:PROVENCIO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1654 151ST AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94578-1956
Mailing Address - Country:US
Mailing Address - Phone:520-240-5118
Mailing Address - Fax:
Practice Address - Street 1:2205 POST ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94115-3427
Practice Address - Country:US
Practice Address - Phone:415-390-6511
Practice Address - Fax:415-592-1617
Is Sole Proprietor?:No
Enumeration Date:2021-10-26
Last Update Date:2023-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant