Provider Demographics
NPI:1023486644
Name:DURIVAGE, GERALD J (CRNP)
Entity type:Individual
Prefix:
First Name:GERALD
Middle Name:J
Last Name:DURIVAGE
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:826 NORTH BROAD ST
Mailing Address - Street 2:
Mailing Address - City:LANSDALE
Mailing Address - State:PA
Mailing Address - Zip Code:19446
Mailing Address - Country:US
Mailing Address - Phone:215-855-1054
Mailing Address - Fax:215-855-3786
Practice Address - Street 1:826 N BROAD ST
Practice Address - Street 2:
Practice Address - City:LANSDALE
Practice Address - State:PA
Practice Address - Zip Code:19446
Practice Address - Country:US
Practice Address - Phone:215-855-1054
Practice Address - Fax:215-855-3786
Is Sole Proprietor?:No
Enumeration Date:2015-09-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP015225363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner