Provider Demographics
NPI:1164013546
Name:GANJI, GELAREH (PA-C)
Entity Type:Individual
Prefix:
First Name:GELAREH
Middle Name:
Last Name:GANJI
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:ROSE
Other - Middle Name:
Other - Last Name:GANJI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:10790 RANCHO BERNARDO RD
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92127-5705
Mailing Address - Country:US
Mailing Address - Phone:858-824-5404
Mailing Address - Fax:
Practice Address - Street 1:11944 CAMINITO CORRIENTE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92128-4515
Practice Address - Country:US
Practice Address - Phone:612-242-6169
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-28
Last Update Date:2021-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA59147363A00000X
363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty