Healthcare Provider Details

I. General information

NPI: 1700712585
Provider Name (Legal Business Name): GWYNETH FUNAN BOYER PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 N VERMONT AVE
LOS ANGELES CA
90004-2115
US

IV. Provider business mailing address

590 N VERMONT AVE
LOS ANGELES CA
90004-2115
US

V. Phone/Fax

Practice location:
  • Phone: 323-284-7998
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number68505
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: