Healthcare Provider Details

I. General information

NPI: 1417022013
Provider Name (Legal Business Name): GWEN S JANCZYK PA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: GWEN S WHITEHEAD PA

II. Dates (important events)

Enumeration Date: 11/21/2006
Last Update Date: 01/29/2020
Certification Date: 01/29/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9898 GENESEE AVE
LA JOLLA CA
92037-1205
US

IV. Provider business mailing address

10790 RANCHO BERNARDO RD
SAN DIEGO CA
92127-5705
US

V. Phone/Fax

Practice location:
  • Phone: 858-824-5353
  • Fax:
Mailing address:
  • Phone: 858-824-5353
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA15930
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA15930
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: