1902260672 NPI number — RAIA IVANKA CIMATU NOVAK PA

Table of content: RAIA IVANKA CIMATU NOVAK PA (NPI 1902260672)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902260672 NPI number — RAIA IVANKA CIMATU NOVAK PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOVAK
Provider First Name:
RAIA IVANKA
Provider Middle Name:
CIMATU
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CIMATU
Provider Other First Name:
RAIA IVANKA
Provider Other Middle Name:
BULATAO
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PA
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1902260672
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/08/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2572 ATLANTIC AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONG BEACH
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90806-2751
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
562-774-0844
Provider Business Mailing Address Fax Number:
562-774-0848

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2572 ATLANTIC AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONG BEACH
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90806-2751
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
562-774-0844
Provider Business Practice Location Address Fax Number:
562-774-0848
Provider Enumeration Date:
04/08/2016

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363A00000X , with the licence number:  53287 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: PA53287 . This is a "PHYSICIAN ASSISTANT BOARD - STATE OF CALIFORNIA" identifier , issued by the state of ( CA ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com