Provider Demographics
NPI:1487118105
Name:DEKLEUVER, RODNEY GERRIT (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:RODNEY
Middle Name:GERRIT
Last Name:DEKLEUVER
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 MONTGOMERY DR
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4557
Mailing Address - Country:US
Mailing Address - Phone:707-522-5411
Mailing Address - Fax:
Practice Address - Street 1:1405 MONTGOMERY DR
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4557
Practice Address - Country:US
Practice Address - Phone:707-522-5411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-27
Last Update Date:2019-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA56437363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant