Healthcare Provider Details

I. General information

NPI: 1497965529
Provider Name (Legal Business Name): RAYMOND A CERVENKA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 12/03/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 N WATERMAN AVE
SAN BERNARDINO CA
92404-4811
US

IV. Provider business mailing address

PO BOX 10488
SAN BERNARDINO CA
92423-0488
US

V. Phone/Fax

Practice location:
  • Phone: 909-886-4971
  • Fax: 909-883-0459
Mailing address:
  • Phone: 909-335-7171
  • Fax: 909-335-7140

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA13903
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: