Provider Demographics
NPI:1295952034
Name:GERVASI-LYTTKENS, GEORGANN (PA-C, RDCS,RVT)
Entity type:Individual
Prefix:
First Name:GEORGANN
Middle Name:
Last Name:GERVASI-LYTTKENS
Suffix:
Gender:F
Credentials:PA-C, RDCS,RVT
Other - Prefix:
Other - First Name:GEORGANN
Other - Middle Name:
Other - Last Name:GERVASI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C, RDCS,RVT
Mailing Address - Street 1:2333 MOWRY AVE
Mailing Address - Street 2:SUITE #220
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-1625
Mailing Address - Country:US
Mailing Address - Phone:510-792-2012
Mailing Address - Fax:510-792-7986
Practice Address - Street 1:2333 MOWRY AVE
Practice Address - Street 2:SUITE #220
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-1625
Practice Address - Country:US
Practice Address - Phone:510-792-2012
Practice Address - Fax:510-792-7986
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2016-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X, 363AM0700X
CAPA137042085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13704OtherPHYSICIAN ASSIST. LICENSE