Healthcare Provider Details

I. General information

NPI: 1285242032
Provider Name (Legal Business Name): GABRIEL SOUSA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2020
Last Update Date: 11/30/2020
Certification Date: 11/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1114 6TH ST
MODESTO CA
95354-2203
US

IV. Provider business mailing address

737 W CHILDS AVE
MERCED CA
95341-6805
US

V. Phone/Fax

Practice location:
  • Phone: 866-682-4842
  • Fax: 877-436-1494
Mailing address:
  • Phone: 866-682-4842
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number58744
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: