Healthcare Provider Details

I. General information

NPI: 1457914772
Provider Name (Legal Business Name): GAGAN TAKHAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

80 DECLARATION DR
CHICO CA
95973-4900
US

IV. Provider business mailing address

5757 PACIFIC AVE STE 228
STOCKTON CA
95207-5159
US

V. Phone/Fax

Practice location:
  • Phone: 530-894-6832
  • Fax: 530-342-4199
Mailing address:
  • Phone: 209-490-5050
  • Fax: 209-779-6211

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA56910
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: