Provider Demographics
NPI:1245757194
Name:OGG, AUDREY ROSALES (PA-C)
Entity Type:Individual
Prefix:
First Name:AUDREY
Middle Name:ROSALES
Last Name:OGG
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:PO BOX 1436
Mailing Address - Street 2:
Mailing Address - City:SAUSALITO
Mailing Address - State:CA
Mailing Address - Zip Code:94966-1436
Mailing Address - Country:US
Mailing Address - Phone:415-730-5876
Mailing Address - Fax:
Practice Address - Street 1:24 WILLIE MAYS PLZ
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94107-2134
Practice Address - Country:US
Practice Address - Phone:415-730-5876
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA54769363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant