MEDICARE: NICOLE JACQUELINE GAJADHAR PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	65712	CA
2	363AM0700X	Medical Physician Assistant	7128	CT
3	363AM0700X	Medical Physician Assistant	011033-1	NY

General Provider Information

NPI Number	:	1457405524
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE JACQUELINE GAJADHAR PA-C

Provider Business Mailing Address
First Line	:	823 GATEWAY CENTER WAY
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92102-4541
Country	:	US
Telephone Number	:	619-515-2300
Fax Number	:

Provider Business Practice Location Address
First Line	:	3544 30TH ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92104-4120
Country	:	US
Telephone Number	:	619-515-2424
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/23/2007
Last Update Date	:	02/09/2026

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