Provider Demographics
NPI:1447647391
Name:CERECERES, TIMOTHY (NP)
Entity type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:
Last Name:CERECERES
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4156 MANZANITA AVE
Mailing Address - Street 2:
Mailing Address - City:CARMICHAEL
Mailing Address - State:CA
Mailing Address - Zip Code:95608-1496
Mailing Address - Country:US
Mailing Address - Phone:916-488-6337
Mailing Address - Fax:
Practice Address - Street 1:4156 MANZANITA AVE
Practice Address - Street 2:
Practice Address - City:CARMICHAEL
Practice Address - State:CA
Practice Address - Zip Code:95608-1496
Practice Address - Country:US
Practice Address - Phone:916-488-6337
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-17
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA958001706363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA95001706OtherCALIFORNIA BOARD OF REGISTERED NURSES