Provider Demographics
NPI:1982689626
Name:DALES, GREGORY L
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:L
Last Name:DALES
Suffix:
Gender:M
Credentials:
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 1807
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:CA
Mailing Address - Zip Code:95634-1807
Mailing Address - Country:US
Mailing Address - Phone:530-333-2555
Mailing Address - Fax:530-333-2832
Practice Address - Street 1:6065 HIGHWAY 193
Practice Address - Street 2:
Practice Address - City:GEORGETOWN
Practice Address - State:CA
Practice Address - Zip Code:95634
Practice Address - Country:US
Practice Address - Phone:530-333-2555
Practice Address - Fax:530-333-2832
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CARN369163163W00000X
CANP6962363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse