Provider Demographics
NPI:1740512466
Name:GALLARDO, GABRIELA ROMERO (PA)
Entity type:Individual
Prefix:
First Name:GABRIELA
Middle Name:ROMERO
Last Name:GALLARDO
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 1:968 L PORTER CT
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-4120
Mailing Address - Country:US
Mailing Address - Phone:760-562-6153
Mailing Address - Fax:
Practice Address - Street 1:1415 ROSS AVE
Practice Address - Street 2:
Practice Address - City:EL CENTRO
Practice Address - State:CA
Practice Address - Zip Code:92243-4306
Practice Address - Country:US
Practice Address - Phone:760-339-7254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-04
Last Update Date:2010-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20813363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1740512466Medicaid
CA1740512466Medicaid