Provider Demographics
NPI:1912946567
Name:GASTELUM, GINA ROSE (PAC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:ROSE
Last Name:GASTELUM
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:200 W CENTER STREET PROMENADE STE 300
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3960
Mailing Address - Country:US
Mailing Address - Phone:714-449-4841
Mailing Address - Fax:714-937-6233
Practice Address - Street 1:3307 RENNER DR
Practice Address - Street 2:
Practice Address - City:FORTUNA
Practice Address - State:CA
Practice Address - Zip Code:95540-3119
Practice Address - Country:US
Practice Address - Phone:707-725-9832
Practice Address - Fax:707-725-7247
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-06
Last Update Date:2021-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15240363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15240Medicaid
CA0PA152402Medicare PIN
CA0PA152401Medicare PIN
CAP32518Medicare UPIN