Provider Demographics
NPI:1952462335
Name:BROTHERTON, GREGORY PAUL (HAS)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:PAUL
Last Name:BROTHERTON
Suffix:
Gender:M
Credentials:HAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:819 S STATE HIGHWAY 49
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:CA
Mailing Address - Zip Code:95642-2622
Mailing Address - Country:US
Mailing Address - Phone:209-223-2436
Mailing Address - Fax:209-257-0729
Practice Address - Street 1:819 S STATE HIGHWAY 49
Practice Address - Street 2:819 S STATE HIGHWAY 49
Practice Address - City:JACKSON
Practice Address - State:CA
Practice Address - Zip Code:95642-2622
Practice Address - Country:US
Practice Address - Phone:209-223-2436
Practice Address - Fax:209-257-0729
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAHA2805237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA680406337OtherEIN