Healthcare Provider Details

I. General information

NPI: 1245500065
Provider Name (Legal Business Name): JEVON PATRICK GEGG-MITCHELL PA-C, FNP, RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2012
Last Update Date: 09/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PASTEUR DR
STANFORD CA
94305-2200
US

IV. Provider business mailing address

1804 EMBARCADERO RD STE 100
PALO ALTO CA
94303-3341
US

V. Phone/Fax

Practice location:
  • Phone: 650-723-4000
  • Fax:
Mailing address:
  • Phone: 650-723-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number769525
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA22395
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95000037
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: