MEDICARE: ERA MAE CHUA GIBBONS

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95014355	CA

General Provider Information

NPI Number	:	1013546878
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ERA MAE CHUA GIBBONS

Provider Business Mailing Address
First Line	:	4020 W 59TH ST
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90043-3412
Country	:	US
Telephone Number	:	323-535-2111
Fax Number	:

Provider Business Practice Location Address
First Line	:	1655 S WESTERN AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90006-5801
Country	:	US
Telephone Number	:	323-737-5200
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/03/2020
Last Update Date	:	04/03/2020

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