Provider Demographics
NPI:1710917018
Name:ROLL, GUNNAR (PA)
Entity Type:Individual
Prefix:
First Name:GUNNAR
Middle Name:
Last Name:ROLL
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:GUNNAR
Other - Middle Name:
Other - Last Name:ROLL
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA C
Mailing Address - Street 1:4355 GLADYS AVE
Mailing Address - Street 2:
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95062-4509
Mailing Address - Country:US
Mailing Address - Phone:831-462-9585
Mailing Address - Fax:
Practice Address - Street 1:75 NIELSON STREET
Practice Address - Street 2:
Practice Address - City:WATSONVILLE
Practice Address - State:CA
Practice Address - Zip Code:95076
Practice Address - Country:US
Practice Address - Phone:408-724-4741
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2008-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA12560363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA16537Medicaid
Q67980Medicare UPIN
CAPA16537Medicaid
CAAW413ZMedicare PIN
CAP74695Medicare UPIN