Healthcare Provider Details

I. General information

NPI: 1932314770
Provider Name (Legal Business Name): JAN WARREN PIENCENAVES JALOSJOS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/14/2007
Last Update Date: 02/09/2022
Certification Date: 02/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5501 OLD YORK RD
PHILADELPHIA PA
19141-3018
US

IV. Provider business mailing address

304 CHESTNUT AVENUE
WOODLYNNE NJ
08107
US

V. Phone/Fax

Practice location:
  • Phone: 215-456-7900
  • Fax:
Mailing address:
  • Phone: 267-307-5795
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA052733
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberMA052733
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberOA002134
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberOA002134
License Number StatePA
# 5
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberMA052733
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: