Provider Demographics
NPI:1215045059
Name:SALAS, GUSTAVO (PA)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:SALAS
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:P.O. BOX 12020
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-2020
Mailing Address - Country:US
Mailing Address - Phone:888-556-5617
Mailing Address - Fax:
Practice Address - Street 1:2801 'L' STREET
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95816
Practice Address - Country:US
Practice Address - Phone:916-733-3003
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2011-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17738363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17738Medicaid
Q44091Medicare UPIN
CA0PA177380Medicare PIN