Provider Demographics
NPI:1679640072
Name:SERPA, PATRICIA ANN
Entity Type:Individual
Prefix:
First Name:PATRICIA
Middle Name:ANN
Last Name:SERPA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:KATHLEEN
Other - Middle Name:MARIE
Other - Last Name:GORDON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:212 BON AIR SHOPPING CTR
Mailing Address - Street 2:
Mailing Address - City:GREENBRAE
Mailing Address - State:CA
Mailing Address - Zip Code:94904-2416
Mailing Address - Country:US
Mailing Address - Phone:415-461-9222
Mailing Address - Fax:415-461-3958
Practice Address - Street 1:212 BON AIR SHOPPING CTR
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2416
Practice Address - Country:US
Practice Address - Phone:415-461-9222
Practice Address - Fax:415-461-3958
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2009-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD 1956156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0226420001Medicare PIN