Basic Information
| Provider Information | |||||||||
| NPI: | 1598702433 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GATEWOOD | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | A. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1520 SAN PABLO ST | ||||||||
| Address2: | SUITE 3451 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900335310 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234427400 | ||||||||
| FaxNumber: | 3234427411 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 SAN PABLO ST | ||||||||
| Address2: | USC UNIVERSITY HOSPITAL | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900335313 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234427400 | ||||||||
| FaxNumber: | 3234427411 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/31/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 367500000X | 2518 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | P00067590 | 01 | CA | RAILROAD MEDICARE | OTHER | RN5497970328 | 01 | CA | CALOPTIMA | OTHER | RN5497970 | 05 | CA | MEDICAID | ZZZ39324Z | 01 | CA | BLUE SHIELD | OTHER |