Healthcare Provider Details

I. General information

NPI: 1841327491
Provider Name (Legal Business Name): ANTHONY RAYMOND REYES YVANOVICH PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: ANTHONY R. YVANOVICH PA-C

II. Dates (important events)

Enumeration Date: 02/28/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1801
US

IV. Provider business mailing address

700 E WASHINGTON ST #39
COLTON CA
92324-7106
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-1000
  • Fax:
Mailing address:
  • Phone: 909-433-0483
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA 19021
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: