=====================================================
General NPI Number Information
=====================================================
NPI Number | 1013230440
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MIRIAM MONA GAFFER FERREIRA PA-C
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/12/2010
-----------------------------------------------------
Last Update Date | 03/12/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2828 TELEGRAPH AVE
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94705-1119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-848-8404
-----------------------------------------------------
Fax | 510-848-6312
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 28094 PETRINA CT
-----------------------------------------------------
City | HAYWARD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94545-4968
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-783-5978
-----------------------------------------------------
Fax | 510-783-5978
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | PA20883
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------