Healthcare Provider Details

I. General information

NPI: 1114513132
Provider Name (Legal Business Name): FELICIA GU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2020
Last Update Date: 12/15/2020
Certification Date: 12/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 W 58TH ST
LOS ANGELES CA
90037-3632
US

IV. Provider business mailing address

PO BOX 11002
GLENDALE CA
91226-7002
US

V. Phone/Fax

Practice location:
  • Phone: 323-541-1411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58658
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: