Provider Demographics
NPI:1477665602
Name:GHOSH, RAE-LYNN MICHELLE (PA)
Entity type:Individual
Prefix:
First Name:RAE-LYNN
Middle Name:MICHELLE
Last Name:GHOSH
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:RAE LYNN
Other - Middle Name:MICHELLE
Other - Last Name:COUTURE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:P.O. BOX 2200
Mailing Address - Street 2:
Mailing Address - City:REDLANDS
Mailing Address - State:CA
Mailing Address - Zip Code:92373-0722
Mailing Address - Country:US
Mailing Address - Phone:909-793-3311
Mailing Address - Fax:909-796-4158
Practice Address - Street 1:2 WEST FERN AVE
Practice Address - Street 2:
Practice Address - City:REDLANDS
Practice Address - State:CA
Practice Address - Zip Code:92373-5916
Practice Address - Country:US
Practice Address - Phone:909-793-3311
Practice Address - Fax:909-796-4158
Is Sole Proprietor?:No
Enumeration Date:2006-09-01
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant