Provider Demographics
NPI:1659493674
Name:GOSLA, NAZEMA (PA)
Entity Type:Individual
Prefix:
First Name:NAZEMA
Middle Name:
Last Name:GOSLA
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:1665 SCENIC AVE. SUITE 100
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626
Mailing Address - Country:US
Mailing Address - Phone:714-442-4864
Mailing Address - Fax:714-442-4892
Practice Address - Street 1:13152 NEWPORT AVE
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780
Practice Address - Country:US
Practice Address - Phone:714-442-4864
Practice Address - Fax:714-442-4892
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-03
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA15465363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant