Basic Information
| Provider Information | |||||||||
| NPI: | 1104229178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GATMAITAN | ||||||||
| FirstName: | DYANE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4140 W 190TH ST | ||||||||
| Address2: | |||||||||
| City: | TORRANCE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 905045513 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104236472 | ||||||||
| FaxNumber: | 3104238839 | ||||||||
| Practice Location | |||||||||
| Address1: | 127 S SAN VICENTE BLVD # A-6600 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900483311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104236472 | ||||||||
| FaxNumber: | 3104238839 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2014 | ||||||||
| LastUpdateDate: | 06/08/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/08/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 95001144 | CA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LG0600X | 95001144 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
No ID Information.