Provider Demographics
NPI:1457440869
Name:BROUGHAL, GABRIELA (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:GABRIELA
Middle Name:
Last Name:BROUGHAL
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 1:5855 OLIVAS PARK DR
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-7672
Mailing Address - Country:US
Mailing Address - Phone:805-667-2801
Mailing Address - Fax:805-641-1706
Practice Address - Street 1:138 WEST MAIN STREET
Practice Address - Street 2:SUITE E,F,G
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93001-0000
Practice Address - Country:US
Practice Address - Phone:323-646-2997
Practice Address - Fax:805-667-2851
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2011-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15282363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM08609FMedicaid
CARHM08608FMedicaid
CARHM18553HMedicaid
CAZZT40394FMedicaid
CA95-1683892OtherOTHER INSURANCE
CARHM08608FMedicaid
CARHM08609FMedicaid