Provider Demographics
NPI:1497965529
Name:CERVENKA, RAYMOND A (PA)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:A
Last Name:CERVENKA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 10488
Mailing Address - Street 2:
Mailing Address - City:SAN BERNARDINO
Mailing Address - State:CA
Mailing Address - Zip Code:92423-0488
Mailing Address - Country:US
Mailing Address - Phone:909-335-7171
Mailing Address - Fax:909-335-7140
Practice Address - Street 1:2150 N WATERMAN AVE
Practice Address - Street 2:
Practice Address - City:SAN BERNARDINO
Practice Address - State:CA
Practice Address - Zip Code:92404-4811
Practice Address - Country:US
Practice Address - Phone:909-886-4971
Practice Address - Fax:909-883-0459
Is Sole Proprietor?:No
Enumeration Date:2007-05-24
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA13903363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant