Provider Demographics
NPI:1225541873
Name:CERVANTES, MARTHA (PA-S)
Entity Type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:PA-S
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8700 BEVERLY BLVD
Mailing Address - Street 2:
Mailing Address - City:WEST HOLLYWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90048-1804
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:120 S SPALDING DR STE 400
Practice Address - Street 2:
Practice Address - City:BEVERLY HILLS
Practice Address - State:CA
Practice Address - Zip Code:90212-1842
Practice Address - Country:US
Practice Address - Phone:310-659-2724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-11-06
Last Update Date:2020-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363A00000X
CAPA55367363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant