Provider Demographics
NPI:1235893645
Name:GENTRY, EMILY RUTHANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:EMILY
Middle Name:RUTHANNE
Last Name:GENTRY
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:39141 CIVIC CENTER DR STE 335
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:CA
Mailing Address - Zip Code:94538-5878
Mailing Address - Country:US
Mailing Address - Phone:510-248-1450
Mailing Address - Fax:
Practice Address - Street 1:39141 CIVIC CENTER DR STE 335
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:CA
Practice Address - Zip Code:94538-5878
Practice Address - Country:US
Practice Address - Phone:510-248-1450
Practice Address - Fax:510-742-8244
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-22
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA60937363A00000X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgicalGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty