Provider Demographics
NPI:1780007708
Name:NOSOVITSKY, GENNADY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GENNADY
Middle Name:
Last Name:NOSOVITSKY
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 1:68555 RAMON RD STE D103
Mailing Address - Street 2:
Mailing Address - City:CATHEDRAL CITY
Mailing Address - State:CA
Mailing Address - Zip Code:92234-3310
Mailing Address - Country:US
Mailing Address - Phone:760-676-5800
Mailing Address - Fax:858-634-6960
Practice Address - Street 1:68555 RAMON RD
Practice Address - Street 2:SUITE D103 & D104
Practice Address - City:CATHEDRAL CITY
Practice Address - State:CA
Practice Address - Zip Code:92234-3310
Practice Address - Country:US
Practice Address - Phone:760-507-3310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-27
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA23278363AM0700X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical