Provider Demographics
NPI:1821573593
Name:VAUGHAN, GISELLE DE GUZMAN (PA-C)
Entity Type:Individual
Prefix:
First Name:GISELLE
Middle Name:DE GUZMAN
Last Name:VAUGHAN
Suffix:
Gender:F
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:PO BOX 7068
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0068
Mailing Address - Country:US
Mailing Address - Phone:757-686-3508
Mailing Address - Fax:757-686-0541
Practice Address - Street 1:816 INDEPENDENCE BLVD STE 2H
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23455-6010
Practice Address - Country:US
Practice Address - Phone:757-363-6850
Practice Address - Fax:757-822-6226
Is Sole Proprietor?:No
Enumeration Date:2018-09-28
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110007140363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant