Provider Demographics
NPI:1659899813
Name:LIEVANOS, JENNIFER CRYSTAL (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:CRYSTAL
Last Name:LIEVANOS
Suffix:
Gender:F
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 1:4234 RIVERWALK PKWY STE 230
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92505-3312
Mailing Address - Country:US
Mailing Address - Phone:951-781-3672
Mailing Address - Fax:
Practice Address - Street 1:4234 RIVERWALK PKWY STE 230
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92505-3312
Practice Address - Country:US
Practice Address - Phone:951-781-3672
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-07
Last Update Date:2017-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54695363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant