Provider Demographics
NPI:1285998690
Name:NISPEROS, MARICHU (PA-C)
Entity type:Individual
Prefix:
First Name:MARICHU
Middle Name:
Last Name:NISPEROS
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 1:515 RAINWELL DR
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95133-1934
Mailing Address - Country:US
Mailing Address - Phone:408-482-9788
Mailing Address - Fax:
Practice Address - Street 1:330 NORTHGATE DR
Practice Address - Street 2:
Practice Address - City:MANTECA
Practice Address - State:CA
Practice Address - Zip Code:95336-3139
Practice Address - Country:US
Practice Address - Phone:209-239-1996
Practice Address - Fax:209-239-2876
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-29
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17851363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant