Provider Demographics
NPI:1467494906
Name:EMBLAD, GILLIAN L (PA)
Entity Type:Individual
Prefix:MRS
First Name:GILLIAN
Middle Name:L
Last Name:EMBLAD
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GILLIAN
Other - Middle Name:
Other - Last Name:LEWKE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:50 MILLAY PL
Mailing Address - Street 2:
Mailing Address - City:MILL VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:94941-1501
Mailing Address - Country:US
Mailing Address - Phone:415-888-8414
Mailing Address - Fax:
Practice Address - Street 1:901 NEVIN AVE
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:CA
Practice Address - Zip Code:94801-3143
Practice Address - Country:US
Practice Address - Phone:510-307-1500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-11
Last Update Date:2022-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16198363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16198Medicaid
CAOPA161981Medicare ID - Type Unspecified
P50581Medicare UPIN