Provider Demographics
NPI:1518310333
Name:JEREMIAH, GASTON (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:
First Name:GASTON
Middle Name:
Last Name:JEREMIAH
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:820 SUNGROVE PL
Mailing Address - Street 2:
Mailing Address - City:BREA
Mailing Address - State:CA
Mailing Address - Zip Code:92821-4130
Mailing Address - Country:US
Mailing Address - Phone:646-299-2402
Mailing Address - Fax:
Practice Address - Street 1:1310 W STEWART DR STE 503
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-3856
Practice Address - Country:US
Practice Address - Phone:714-997-2224
Practice Address - Fax:714-997-1187
Is Sole Proprietor?:No
Enumeration Date:2016-07-16
Last Update Date:2024-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3746363A00000X, 363AS0400X
CA55591363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA55591OtherPA
CA1131297OtherNPPES