Provider Demographics
NPI:1669676300
Name:RAMOS, GUSTAVO (PA-C)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:RAMOS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30141 ANTELOPE RD # D-329
Mailing Address - Street 2:
Mailing Address - City:MENIFEE
Mailing Address - State:CA
Mailing Address - Zip Code:92584-8066
Mailing Address - Country:US
Mailing Address - Phone:951-227-1155
Mailing Address - Fax:
Practice Address - Street 1:400 W 30TH ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-3320
Practice Address - Country:US
Practice Address - Phone:213-284-3200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15277363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15277Medicaid