Provider Demographics
NPI:1972561272
Name:IVANIC, TOREY SUE (PA-C)
Entity Type:Individual
Prefix:
First Name:TOREY
Middle Name:SUE
Last Name:IVANIC
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TOREY
Other - Middle Name:SUE
Other - Last Name:VOTAW
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:330 E PINE ST
Mailing Address - Street 2:
Mailing Address - City:EXETER
Mailing Address - State:CA
Mailing Address - Zip Code:93221-1838
Mailing Address - Country:US
Mailing Address - Phone:559-592-2134
Mailing Address - Fax:559-592-5017
Practice Address - Street 1:330 E PINE ST
Practice Address - Street 2:
Practice Address - City:EXETER
Practice Address - State:CA
Practice Address - Zip Code:93221-1838
Practice Address - Country:US
Practice Address - Phone:559-592-2134
Practice Address - Fax:559-592-5017
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2012-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17060363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAQ05779Medicare UPIN