Healthcare Provider Details

I. General information

NPI: 1073756235
Provider Name (Legal Business Name): ILEANA CERVANTES PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ILEANA TREBAOL PA-C

II. Dates (important events)

Enumeration Date: 04/16/2009
Last Update Date: 04/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2139 E BEECHWOOD AVE
FRESNO CA
93720-0340
US

IV. Provider business mailing address

5535 W HARTER AVE
VISALIA CA
93277-3726
US

V. Phone/Fax

Practice location:
  • Phone: 559-322-6600
  • Fax: 559-322-4209
Mailing address:
  • Phone: 559-635-2014
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA 18110
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: