Provider Demographics
NPI:1871708859
Name:GALLARDO, ANDRE V (OTR, PA)
Entity type:Individual
Prefix:MR
First Name:ANDRE
Middle Name:V
Last Name:GALLARDO
Suffix:
Gender:M
Credentials:OTR, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5551 MOSSVALE CIR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92649-4824
Mailing Address - Country:US
Mailing Address - Phone:714-206-9884
Mailing Address - Fax:714-908-2211
Practice Address - Street 1:16200 AMBER VALLEY DR
Practice Address - Street 2:
Practice Address - City:WHITTIER
Practice Address - State:CA
Practice Address - Zip Code:90604-4051
Practice Address - Country:US
Practice Address - Phone:562-943-7125
Practice Address - Fax:562-903-3398
Is Sole Proprietor?:No
Enumeration Date:2007-05-11
Last Update Date:2018-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4374225X00000X
CA19169363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19169OtherPHYSICIAN'S ASSISTANT
CAOT 4374OtherOCCUPATIONAL THERAPIST