Provider Demographics
NPI:1841202165
Name:GOETTSCH, DEBRA SUE (PA-C)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:SUE
Last Name:GOETTSCH
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 1:1801 SHATTUCK AVE STE A
Mailing Address - Street 2:
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94709-1872
Mailing Address - Country:US
Mailing Address - Phone:510-225-1025
Mailing Address - Fax:510-225-0119
Practice Address - Street 1:1801 SHATTUCK AVE STE A
Practice Address - Street 2:
Practice Address - City:BERKELEY
Practice Address - State:CA
Practice Address - Zip Code:94709-1872
Practice Address - Country:US
Practice Address - Phone:510-225-1025
Practice Address - Fax:510-225-0119
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13453363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAR95016Medicare UPIN