Provider Demographics
NPI:1952069387
Name:ROCHA, GUSTAVO (PA)
Entity Type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:
Last Name:ROCHA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:22607 CARRIAGE BUSH
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261-4420
Mailing Address - Country:US
Mailing Address - Phone:210-421-1833
Mailing Address - Fax:
Practice Address - Street 1:22607 CARRIAGE BUSH
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78261-4420
Practice Address - Country:US
Practice Address - Phone:210-421-1833
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-12-02
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9539363AM0700X
PR1150-P.A.363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical