Provider Demographics
NPI:1790766566
Name:VANRAVENSWAAY, PAUL ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:ALEXANDER
Last Name:VANRAVENSWAAY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:125 SOLANO ST
Mailing Address - Street 2:
Mailing Address - City:TIBURON
Mailing Address - State:CA
Mailing Address - Zip Code:94920-1969
Mailing Address - Country:US
Mailing Address - Phone:415-900-5022
Mailing Address - Fax:
Practice Address - Street 1:125 SOLANO ST
Practice Address - Street 2:
Practice Address - City:TIBURON
Practice Address - State:CA
Practice Address - Zip Code:94920-1969
Practice Address - Country:US
Practice Address - Phone:415-900-5022
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-09
Last Update Date:2015-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG1325702084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
B36559Medicare UPIN
MD222L064XMedicare ID - Type Unspecified