Healthcare Provider Details

I. General information

NPI: 1811723406
Provider Name (Legal Business Name): MEGAN GLEASON PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MEGAN BALLWEBER

II. Dates (important events)

Enumeration Date: 09/10/2024
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 S ELISEO DR STE 2A
GREENBRAE CA
94904-2017
US

IV. Provider business mailing address

171 SAN ANDREAS DR
NOVATO CA
94945-1654
US

V. Phone/Fax

Practice location:
  • Phone: 415-464-5400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA68379
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: