Healthcare Provider Details

I. General information

NPI: 1699692939
Provider Name (Legal Business Name): JERVIS PATRICK ESTRELLA LUCAS PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/29/2026
Last Update Date: 06/29/2026
Certification Date: 06/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 CANYON ROCK RD APT A
PALM SPRINGS CA
92264-0541
US

IV. Provider business mailing address

108 CANYON ROCK RD APT A
PALM SPRINGS CA
92264-0541
US

V. Phone/Fax

Practice location:
  • Phone: 310-367-7045
  • Fax:
Mailing address:
  • Phone: 310-367-7045
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number54460
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: