Provider Demographics
NPI:1861036964
Name:GOTTFELD, DUSTIN BRYCE (PA-C)
Entity Type:Individual
Prefix:
First Name:DUSTIN
Middle Name:BRYCE
Last Name:GOTTFELD
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 1:48 57TH PL
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90803-4414
Mailing Address - Country:US
Mailing Address - Phone:310-709-1490
Mailing Address - Fax:
Practice Address - Street 1:28078 BAXTER RD STE 530
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-1405
Practice Address - Country:US
Practice Address - Phone:310-709-1490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-31
Last Update Date:2021-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA59175363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant