Provider Demographics
NPI:1699802710
Name:WARGALA, ALYSSA KATHRYN (PA)
Entity type:Individual
Prefix:
First Name:ALYSSA
Middle Name:KATHRYN
Last Name:WARGALA
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 1:12501 WANDERER RD
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:CA
Mailing Address - Zip Code:95602-8124
Mailing Address - Country:US
Mailing Address - Phone:530-613-3725
Mailing Address - Fax:
Practice Address - Street 1:2090 NEVADA CITY HWY
Practice Address - Street 2:
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945-7702
Practice Address - Country:US
Practice Address - Phone:530-274-5020
Practice Address - Fax:530-274-6687
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15236363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15236OtherPHYSICIAN ASSISTANT