Provider Demographics
NPI:1154432672
Name:KALTMAN, MARLA GWEN (PA)
Entity type:Individual
Prefix:MS
First Name:MARLA
Middle Name:GWEN
Last Name:KALTMAN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2201 5TH ST
Mailing Address - Street 2:#108
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90405-2457
Mailing Address - Country:US
Mailing Address - Phone:310-801-5319
Mailing Address - Fax:213-482-2998
Practice Address - Street 1:1245 WILSHIRE BLVD
Practice Address - Street 2:#200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90017-4810
Practice Address - Country:US
Practice Address - Phone:213-482-2993
Practice Address - Fax:213-482-2998
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2011-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13614363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA13614OtherSTATE LICENSE
CAPA13614OtherSTATE LICENSE