Provider Demographics
NPI:1740623867
Name:SWAIN, GENISE MARIE (PA-C)
Entity type:Individual
Prefix:MRS
First Name:GENISE
Middle Name:MARIE
Last Name:SWAIN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MS
Other - First Name:GENISE
Other - Middle Name:MARIE
Other - Last Name:DEROSA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:30 DEUCE CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:CA
Mailing Address - Zip Code:94930-1308
Mailing Address - Country:US
Mailing Address - Phone:415-456-2746
Mailing Address - Fax:
Practice Address - Street 1:731 EL CERRITO PLZ
Practice Address - Street 2:
Practice Address - City:EL CERRITO
Practice Address - State:CA
Practice Address - Zip Code:94530-4022
Practice Address - Country:US
Practice Address - Phone:510-559-7975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-08
Last Update Date:2013-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14833363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant