Provider Demographics
NPI:1679922777
Name:SERRAVO, GARY ANTHONY (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:ANTHONY
Last Name:SERRAVO
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 1:400 W 16TH ST
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81003-2745
Mailing Address - Country:US
Mailing Address - Phone:719-584-4306
Mailing Address - Fax:719-584-4861
Practice Address - Street 1:400 W 16TH ST
Practice Address - Street 2:
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2745
Practice Address - Country:US
Practice Address - Phone:719-584-4306
Practice Address - Fax:719-584-4861
Is Sole Proprietor?:No
Enumeration Date:2016-06-09
Last Update Date:2016-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPA.0004647363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO0004647OtherPHYSICIAN ASSISTANT STATE CERTIFICATION