Provider Demographics
NPI:1407188006
Name:TARAVELLA, SONYA N (PA)
Entity Type:Individual
Prefix:
First Name:SONYA
Middle Name:N
Last Name:TARAVELLA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:200 PORTER DR
Mailing Address - Street 2:101
Mailing Address - City:SAN RAMON
Mailing Address - State:CA
Mailing Address - Zip Code:94583-1587
Mailing Address - Country:US
Mailing Address - Phone:925-362-2139
Mailing Address - Fax:923-838-7836
Practice Address - Street 1:5801 NORRIS CANYON RD
Practice Address - Street 2:210
Practice Address - City:SAN RAMON
Practice Address - State:CA
Practice Address - Zip Code:94583-5440
Practice Address - Country:US
Practice Address - Phone:925-355-7350
Practice Address - Fax:925-244-1457
Is Sole Proprietor?:No
Enumeration Date:2010-02-05
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 20764363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACW220ZMedicare PIN