Provider Demographics
NPI:1083631790
Name:GONSALVES, BERNADETTE LOUISE (PA)
Entity Type:Individual
Prefix:MS
First Name:BERNADETTE
Middle Name:LOUISE
Last Name:GONSALVES
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:300 N SAN ANTONIO RD
Mailing Address - Street 2:
Mailing Address - City:SANTA BARBARA
Mailing Address - State:CA
Mailing Address - Zip Code:93110-1316
Mailing Address - Country:US
Mailing Address - Phone:805-681-5461
Mailing Address - Fax:
Practice Address - Street 1:2115 CENTERPOINTE PKWY
Practice Address - Street 2:
Practice Address - City:SANTA MARIA
Practice Address - State:CA
Practice Address - Zip Code:93455-1334
Practice Address - Country:US
Practice Address - Phone:805-346-7230
Practice Address - Fax:805-346-7272
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2008-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16394363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16394OtherMED LICENSE
CAWP16394HMedicare PIN
CAPA16394OtherMED LICENSE