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Individual
MIA GAW
Active
Individual
MIA GAW
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
PA-C
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
0110011478
VA
363A00000X
Physician Assistant
Primary
58196
CA
363A00000X
Physician Assistant
MA063329
PA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
19913648
—
CO
Enumeration date
10/11/2016
Last updated
03/20/2026
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