Provider Demographics
NPI:1184658783
Name:DERUSSO, GAYE (PA)
Entity Type:Individual
Prefix:
First Name:GAYE
Middle Name:
Last Name:DERUSSO
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2999 REGENT ST
Mailing Address - Street 2:STE 225
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94705-2190
Mailing Address - Country:US
Mailing Address - Phone:510-704-7760
Mailing Address - Fax:510-704-7765
Practice Address - Street 1:2999 REGENT ST
Practice Address - Street 2:STE 225
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94705-2190
Practice Address - Country:US
Practice Address - Phone:510-704-7760
Practice Address - Fax:510-704-7765
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2013-02-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA15294363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAAT149ZMedicare PIN