Provider Demographics
NPI:1902260672
Name:NOVAK, RAIA IVANKA CIMATU (PA)
Entity Type:Individual
Prefix:
First Name:RAIA IVANKA
Middle Name:CIMATU
Last Name:NOVAK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RAIA IVANKA
Other - Middle Name:BULATAO
Other - Last Name:CIMATU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:2572 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2751
Mailing Address - Country:US
Mailing Address - Phone:562-774-0844
Mailing Address - Fax:562-774-0848
Practice Address - Street 1:2572 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-2751
Practice Address - Country:US
Practice Address - Phone:562-774-0844
Practice Address - Fax:562-774-0848
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-08
Last Update Date:2019-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53287363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA53287OtherPHYSICIAN ASSISTANT BOARD - STATE OF CALIFORNIA