Provider Demographics
NPI:1841327491
Name:YVANOVICH, ANTHONY RAYMOND REYES (PA-C)
Entity type:Individual
Prefix:MR
First Name:ANTHONY RAYMOND
Middle Name:REYES
Last Name:YVANOVICH
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:MR
Other - First Name:ANTHONY
Other - Middle Name:R
Other - Last Name:YVANOVICH
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:700 E WASHINGTON ST
Mailing Address - Street 2:#39
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-7106
Mailing Address - Country:US
Mailing Address - Phone:909-433-0483
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 19021363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical