Provider Demographics
NPI:1215912019
Name:ROHDE-MOE, GUNNAR ERIK (PA-C)
Entity type:Individual
Prefix:
First Name:GUNNAR
Middle Name:ERIK
Last Name:ROHDE-MOE
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14677 DEON DR
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-9662
Mailing Address - Country:US
Mailing Address - Phone:209-532-1844
Mailing Address - Fax:
Practice Address - Street 1:14677 DEON DR
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-9662
Practice Address - Country:US
Practice Address - Phone:209-532-1844
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-14
Last Update Date:2012-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 15041363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA150410Medicare ID - Type Unspecified