Provider Demographics
NPI:1912510165
Name:GERVAIS, ANTONIO SAMUEL (CRNA, RN)
Entity Type:Individual
Prefix:
First Name:ANTONIO
Middle Name:SAMUEL
Last Name:GERVAIS
Suffix:
Gender:M
Credentials:CRNA, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 N 880 E
Mailing Address - Street 2:
Mailing Address - City:SPRINGVILLE
Mailing Address - State:UT
Mailing Address - Zip Code:84663-1156
Mailing Address - Country:US
Mailing Address - Phone:801-687-8382
Mailing Address - Fax:
Practice Address - Street 1:455 SAINT MICHAELS DR
Practice Address - Street 2:
Practice Address - City:SANTA FE
Practice Address - State:NM
Practice Address - Zip Code:87505-7601
Practice Address - Country:US
Practice Address - Phone:505-913-3043
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-27
Last Update Date:2020-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC310047163W00000X
NC134946367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse