Healthcare Provider Details

I. General information

NPI: 1467987586
Provider Name (Legal Business Name): HEATHER CHRISTINE GEBAUER PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 07/02/2024
Certification Date: 07/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

FILE 57326
LOS ANGELES CA
90074-7326
US

V. Phone/Fax

Practice location:
  • Phone: 800-926-8273
  • Fax:
Mailing address:
  • Phone: 800-926-8273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA54759
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: