Provider Demographics
NPI:1376648956
Name:BERNARD, DAWN DENEEZE (PA-C)
Entity Type:Individual
Prefix:
First Name:DAWN
Middle Name:DENEEZE
Last Name:BERNARD
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 1:4131 MANTOVA DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90008-1128
Mailing Address - Country:US
Mailing Address - Phone:323-357-6543
Mailing Address - Fax:323-564-9865
Practice Address - Street 1:10300 COMPTON AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90002-3628
Practice Address - Country:US
Practice Address - Phone:323-357-6543
Practice Address - Fax:323-564-9865
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2012-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13757363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAS48543Medicare UPIN