Basic Information
| Provider Information | |||||||||
| NPI: | 1366443954 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | GERVAIS | ||||||||
| FirstName: | CAROLE | ||||||||
| MiddleName: | EVA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5904 HOLLY AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871132472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5052982505 | ||||||||
| FaxNumber: | 5052982985 | ||||||||
| Practice Location | |||||||||
| Address1: | 5904 HOLLY AVE NE | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871132472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2122478100 | ||||||||
| FaxNumber: | 2122478093 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/03/2005 | ||||||||
| LastUpdateDate: | 04/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/06/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD2017-0881 | NM | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.