Healthcare Provider Details

I. General information

NPI: 1639220825
Provider Name (Legal Business Name): GARY LEE BROWN PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/15/2007
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2585 SAMARITAN DRIVE
SAN JOSE CA
95124-4107
US

IV. Provider business mailing address

3803 S BASCOM AVE
CAMPBELL CA
95008-7317
US

V. Phone/Fax

Practice location:
  • Phone: 408-371-6771
  • Fax: 408-371-6387
Mailing address:
  • Phone: 408-278-3000
  • Fax: 408-266-7232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA11381
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: