Provider Demographics
NPI:1003012162
Name:GAMBLE, DARCESEAN (PA)
Entity Type:Individual
Prefix:MR
First Name:DARCESEAN
Middle Name:
Last Name:GAMBLE
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5137 ONAKNOLL AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-1039
Mailing Address - Country:US
Mailing Address - Phone:310-403-2510
Mailing Address - Fax:
Practice Address - Street 1:4955 VAN NUYS BLVD STE 411
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403-1824
Practice Address - Country:US
Practice Address - Phone:818-784-1195
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 15713363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant