Provider Demographics
NPI:1740312826
Name:VINES-DOUGLAS, GRETA MARLA (PA-C)
Entity type:Individual
Prefix:
First Name:GRETA
Middle Name:MARLA
Last Name:VINES-DOUGLAS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:GRETA
Other - Middle Name:MARLA
Other - Last Name:VINES
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:5823 YORK BLVD # 3
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90042-2634
Mailing Address - Country:US
Mailing Address - Phone:323-255-5643
Mailing Address - Fax:
Practice Address - Street 1:815 WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-6123
Practice Address - Country:US
Practice Address - Phone:323-728-3955
Practice Address - Fax:323-728-6905
Is Sole Proprietor?:No
Enumeration Date:2007-03-12
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13987363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00381919OtherMEDICARE RAILROAD
CAWPA13987BMedicare PIN
CAS94805Medicare UPIN