Provider Demographics
NPI:1255326963
Name:GERVAIS, ROBERT P (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:P
Last Name:GERVAIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15571 N. REEMS RD
Mailing Address - Street 2:
Mailing Address - City:SURPRIZE
Mailing Address - State:AZ
Mailing Address - Zip Code:85374
Mailing Address - Country:US
Mailing Address - Phone:623-544-6932
Mailing Address - Fax:623-321-1070
Practice Address - Street 1:15571 N. REEMS RD
Practice Address - Street 2:
Practice Address - City:SURPRIZE
Practice Address - State:AZ
Practice Address - Zip Code:85374
Practice Address - Country:US
Practice Address - Phone:623-544-6932
Practice Address - Fax:623-321-1070
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2013-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ2036363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ642026Medicaid
AZ642026Medicaid
AZ970028126Medicare PIN
AZZ68792Medicare PIN
P52596Medicare UPIN