Healthcare Provider Details

I. General information

NPI: 1467294934
Provider Name (Legal Business Name): GABRIEL INCLETO BASCARA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/06/2024
Last Update Date: 08/07/2025
Certification Date: 08/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

365 TUOLUMNE ST
VALLEJO CA
94590-5700
US

IV. Provider business mailing address

140 DOLPHIN CT
VALLEJO CA
94589-3324
US

V. Phone/Fax

Practice location:
  • Phone: 707-553-5509
  • Fax:
Mailing address:
  • Phone: 707-319-6368
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: