Healthcare Provider Details

I. General information

NPI: 1417034489
Provider Name (Legal Business Name): GARY VANETSKY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

477 N EL CAMINO REAL C-312
ENCINITAS CA
92024-1328
US

IV. Provider business mailing address

2285 CORPORATE CIR STE 200
HENDERSON NV
89074-7759
US

V. Phone/Fax

Practice location:
  • Phone: 760-436-2300
  • Fax:
Mailing address:
  • Phone: 702-360-2763
  • Fax: 949-783-2880

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA15456
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: