Provider Demographics
NPI:1346559440
Name:ANDERSEN, GRETCHEN JANE (PA- C)
Entity Type:Individual
Prefix:
First Name:GRETCHEN
Middle Name:JANE
Last Name:ANDERSEN
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 1:1336 MANHATTAN BEACH BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5232
Mailing Address - Country:US
Mailing Address - Phone:818-212-8881
Mailing Address - Fax:
Practice Address - Street 1:500 E TEMPLE ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90012-4024
Practice Address - Country:US
Practice Address - Phone:213-978-3800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-07
Last Update Date:2020-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY014249363A00000X
CA22195363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant