Provider Demographics
NPI:1366464471
Name:ESPENSCHIED, COLLEEN GUSTAFSON (PA-C)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:GUSTAFSON
Last Name:ESPENSCHIED
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:COLLEEN
Other - Middle Name:
Other - Last Name:GUSTAFSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:FILE 54433
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90074-0001
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2017 1ST AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101-2033
Practice Address - Country:US
Practice Address - Phone:619-881-4577
Practice Address - Fax:619-231-1031
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2013-04-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17108363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA17108Medicaid
CAPA17108Medicaid
CAWPA17108AMedicare PIN