Healthcare Provider Details

I. General information

NPI: 1194759704
Provider Name (Legal Business Name): GURJEET MAHAL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

734 MOWRY AVE FREMONT MEDICAL GROUP
FREMONT CA
94536-4115
US

IV. Provider business mailing address

734 MOWRY AVE
FREMONT CA
94536-4115
US

V. Phone/Fax

Practice location:
  • Phone: 510-793-3033
  • Fax: 510-793-4952
Mailing address:
  • Phone: 510-793-3033
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA16792
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: