Provider Demographics
NPI:1639220825
Name:BROWN, GARY LEE (PA-C)
Entity Type:Individual
Prefix:MR
First Name:GARY
Middle Name:LEE
Last Name:BROWN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
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Mailing Address - Street 1:3803 S BASCOM AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELL
Mailing Address - State:CA
Mailing Address - Zip Code:95008-7317
Mailing Address - Country:US
Mailing Address - Phone:408-278-3000
Mailing Address - Fax:408-266-7232
Practice Address - Street 1:2585 SAMARITAN DRIVE
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4107
Practice Address - Country:US
Practice Address - Phone:408-371-6771
Practice Address - Fax:408-371-6387
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-15
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA11381363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1012194OtherNCCPA
CAR94585Medicare UPIN