Provider Demographics
NPI:1457914772
Name:TAKHAR, GAGAN
Entity Type:Individual
Prefix:
First Name:GAGAN
Middle Name:
Last Name:TAKHAR
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5757 PACIFIC AVE STE 228
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5159
Mailing Address - Country:US
Mailing Address - Phone:209-490-5050
Mailing Address - Fax:209-779-6211
Practice Address - Street 1:80 DECLARATION DR
Practice Address - Street 2:
Practice Address - City:CHICO
Practice Address - State:CA
Practice Address - Zip Code:95973-4900
Practice Address - Country:US
Practice Address - Phone:530-894-6832
Practice Address - Fax:530-342-4199
Is Sole Proprietor?:No
Enumeration Date:2019-04-22
Last Update Date:2022-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA56910363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant