Provider Demographics
NPI:1558387886
Name:MEYER, GARY LEE
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:LEE
Last Name:MEYER
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12695 CAMINO MIRA DEL MAR
Mailing Address - Street 2:116
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92130-2582
Mailing Address - Country:US
Mailing Address - Phone:858-437-4445
Mailing Address - Fax:858-350-6746
Practice Address - Street 1:4561 DICKEY DR
Practice Address - Street 2:
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91941-5735
Practice Address - Country:US
Practice Address - Phone:619-328-3025
Practice Address - Fax:619-312-0528
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 17549363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical