Provider Demographics
NPI:1013546878
Name:GIBBONS, ERA MAE CHUA
Entity Type:Individual
Prefix:
First Name:ERA MAE
Middle Name:CHUA
Last Name:GIBBONS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 W 59TH ST
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90043-3412
Mailing Address - Country:US
Mailing Address - Phone:323-535-2111
Mailing Address - Fax:
Practice Address - Street 1:1655 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-5801
Practice Address - Country:US
Practice Address - Phone:323-737-5200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-03
Last Update Date:2020-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014355363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily