Provider Demographics
NPI:1659101574
Name:GAU, MCKENNA
Entity type:Individual
Prefix:
First Name:MCKENNA
Middle Name:
Last Name:GAU
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 1:7618 AMBER WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-1604
Mailing Address - Country:US
Mailing Address - Phone:209-981-7724
Mailing Address - Fax:
Practice Address - Street 1:975 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5118
Practice Address - Country:US
Practice Address - Phone:209-334-3411
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-08-05
Last Update Date:2024-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant