Provider Demographics
NPI:1053371377
Name:WESTBROCK, GARY MITCHELL (PA)
Entity type:Individual
Prefix:
First Name:GARY
Middle Name:MITCHELL
Last Name:WESTBROCK
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2603 SILVERWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:PASO ROBLES
Mailing Address - State:CA
Mailing Address - Zip Code:93446-4763
Mailing Address - Country:US
Mailing Address - Phone:805-541-4018
Mailing Address - Fax:805-543-6271
Practice Address - Street 1:715 TANK FARM RD STE A
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-7068
Practice Address - Country:US
Practice Address - Phone:805-541-4018
Practice Address - Fax:805-543-6271
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2024-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16139363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAW18438Medicare ID - Type UnspecifiedGROUP ID #
CAP51128Medicare UPIN
CAWPA16139AMedicare ID - Type UnspecifiedPPIN