Provider Demographics
NPI:1477160141
Name:GUNAWAN, VICTORIA BURRIS (PA-C)
Entity Type:Individual
Prefix:
First Name:VICTORIA
Middle Name:BURRIS
Last Name:GUNAWAN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:VICTORIA
Other - Middle Name:LAYNE
Other - Last Name:BURRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-9600
Mailing Address - Fax:614-293-4200
Practice Address - Street 1:1670 UPHAM DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43210-1250
Practice Address - Country:US
Practice Address - Phone:614-293-9600
Practice Address - Fax:614-366-1215
Is Sole Proprietor?:No
Enumeration Date:2020-09-28
Last Update Date:2023-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC001010706363A00000X
OH50.007738RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant