Provider Demographics
NPI:1093826315
Name:GAUSE, WILLIAM RANDOLPH (NP)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:RANDOLPH
Last Name:GAUSE
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2100 POWELL ST
Mailing Address - Street 2:SUITE 900
Mailing Address - City:EMERYVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:94608-1826
Mailing Address - Country:US
Mailing Address - Phone:510-350-2600
Mailing Address - Fax:
Practice Address - Street 1:9500 ETIWANDA AVE
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91739-9662
Practice Address - Country:US
Practice Address - Phone:909-463-5003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2016-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANPF11429163W00000X
CA44788363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB91979Medicare UPIN