Provider Demographics
NPI:1396016093
Name:GERLACH, MARIE ELLEN (MS, PA-C)
Entity Type:Individual
Prefix:MRS
First Name:MARIE
Middle Name:ELLEN
Last Name:GERLACH
Suffix:
Gender:F
Credentials:MS, PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 TECHNOLOGY DR
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92618-2302
Mailing Address - Country:US
Mailing Address - Phone:949-923-3250
Mailing Address - Fax:855-812-5865
Practice Address - Street 1:26740 TOWNE CENTRE DR
Practice Address - Street 2:
Practice Address - City:FOOTHILL RANCH
Practice Address - State:CA
Practice Address - Zip Code:92610-2839
Practice Address - Country:US
Practice Address - Phone:949-588-9293
Practice Address - Fax:949-588-0409
Is Sole Proprietor?:No
Enumeration Date:2012-01-26
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18155363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18155OtherMEDICAL LICENSE
CAPENDINGOtherMEDICARE