Provider Demographics
NPI:1073756235
Name:CERVANTES, ILEANA (PA-C)
Entity type:Individual
Prefix:
First Name:ILEANA
Middle Name:
Last Name:CERVANTES
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ILEANA
Other - Middle Name:
Other - Last Name:TREBAOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5535 W HARTER AVE
Mailing Address - Street 2:
Mailing Address - City:VISALIA
Mailing Address - State:CA
Mailing Address - Zip Code:93277-3726
Mailing Address - Country:US
Mailing Address - Phone:559-635-2014
Mailing Address - Fax:
Practice Address - Street 1:2139 E BEECHWOOD AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93720-0340
Practice Address - Country:US
Practice Address - Phone:559-322-6600
Practice Address - Fax:559-322-4209
Is Sole Proprietor?:No
Enumeration Date:2009-04-16
Last Update Date:2009-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 18110363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18110OtherPA 18110 CALIFORNIA BOARD LICENSE