Provider Demographics
NPI:1144833989
Name:IVY, TRISHA (PA-C)
Entity type:Individual
Prefix:
First Name:TRISHA
Middle Name:
Last Name:IVY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:TRISHA
Other - Middle Name:
Other - Last Name:TAYLOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:10399 TIVOLI WAY
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-6017
Mailing Address - Country:US
Mailing Address - Phone:909-963-6446
Mailing Address - Fax:
Practice Address - Street 1:350 TERRACINA BLVD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373
Practice Address - Country:US
Practice Address - Phone:909-335-5600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-30
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA58524363A00000X
363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical