Basic Information
| Provider Information | |||||||||
| NPI: | 1457440869 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BROUGHAL | ||||||||
| FirstName: | GABRIELA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5855 OLIVAS PARK DR | ||||||||
| Address2: | |||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930037672 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8056672801 | ||||||||
| FaxNumber: | 8056411706 | ||||||||
| Practice Location | |||||||||
| Address1: | 138 WEST MAIN STREET | ||||||||
| Address2: | SUITE E,F,G | ||||||||
| City: | VENTURA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 930010000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3236462997 | ||||||||
| FaxNumber: | 8056672851 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/12/2006 | ||||||||
| LastUpdateDate: | 12/22/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 15282 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
ID Information
| ID | Type | State | Issuer | Description | RHM08609F | 05 | CA | MEDICAID | RHM08608F | 05 | CA | MEDICAID | RHM18553H | 05 | CA | MEDICAID | ZZT40394F | 05 | CA | MEDICAID | 95-1683892 | 01 | CA | OTHER INSURANCE | OTHER |