Healthcare Provider Details

I. General information

NPI: 1447290648
Provider Name (Legal Business Name): JAN GEBALSKI P.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5974 PENTZ RD EMERGENCY DEPARTMENT
PARADISE CA
95969-5509
US

IV. Provider business mailing address

4551 GLENCOE AVE SUITE 260
MARINA DEL REY CA
90292-6385
US

V. Phone/Fax

Practice location:
  • Phone: 530-877-9361
  • Fax:
Mailing address:
  • Phone: 310-301-2030
  • Fax: 310-306-5247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA11083
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: