Provider Demographics
NPI:1487066965
Name:DAS, GOURAB
Entity type:Individual
Prefix:
First Name:GOURAB
Middle Name:
Last Name:DAS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:477 N EL CAMINO REAL
Mailing Address - Street 2:SUITE # A200
Mailing Address - City:ENCINITAS
Mailing Address - State:CA
Mailing Address - Zip Code:92024-1328
Mailing Address - Country:US
Mailing Address - Phone:760-942-1242
Mailing Address - Fax:
Practice Address - Street 1:477 N EL CAMINO REAL
Practice Address - Street 2:SUITE # A200
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1328
Practice Address - Country:US
Practice Address - Phone:760-942-1242
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-06-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA51621363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant