Healthcare Provider Details

I. General information

NPI: 1902420938
Provider Name (Legal Business Name): DENISE JEAN CORRIVEAU PA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2020
Last Update Date: 05/13/2026
Certification Date: 05/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8008 FROST ST STE 200
SAN DIEGO CA
92123-4207
US

IV. Provider business mailing address

8008 FROST ST STE 200
SAN DIEGO CA
92123-4207
US

V. Phone/Fax

Practice location:
  • Phone: 858-292-7527
  • Fax:
Mailing address:
  • Phone: 858-292-7527
  • Fax: 858-863-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA61332
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: