Provider Demographics
NPI:1376627760
Name:SEGAL GIDAN, FREDDI ILENE (PA-C, PHD)
Entity Type:Individual
Prefix:MS
First Name:FREDDI
Middle Name:ILENE
Last Name:SEGAL GIDAN
Suffix:
Gender:F
Credentials:PA-C, PHD
Other - Prefix:
Other - First Name:FREDDI
Other - Middle Name:ILENE
Other - Last Name:SEGAL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 31309
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90031-0309
Mailing Address - Country:US
Mailing Address - Phone:323-442-5710
Mailing Address - Fax:
Practice Address - Street 1:1520 SAN PABLO ST STE 3000
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-5315
Practice Address - Country:US
Practice Address - Phone:323-442-5710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA10482363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WPA10421Medicare UPIN