Healthcare Provider Details

I. General information

NPI: 1295952034
Provider Name (Legal Business Name): GEORGANN GERVASI-LYTTKENS PA-C, R.D.C.S.,R.V.T
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GEORGANN GERVASI PA-C, R.D.C.S.,R.V.T

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 05/16/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2333 MOWRY AVE SUITE #220
FREMONT CA
94538-1625
US

IV. Provider business mailing address

2333 MOWRY AVE SUITE #220
FREMONT CA
94538-1625
US

V. Phone/Fax

Practice location:
  • Phone: 510-792-2012
  • Fax: 510-792-7986
Mailing address:
  • Phone: 510-792-2012
  • Fax: 510-792-7986

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: