Provider Demographics
NPI:1235242918
Name:SIRKIN, JEANETTE SALAS (NPA)
Entity Type:Individual
Prefix:
First Name:JEANETTE
Middle Name:SALAS
Last Name:SIRKIN
Suffix:
Gender:F
Credentials:NPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:511 N HOLLYWOOD WAY
Mailing Address - Street 2:
Mailing Address - City:BURBANK
Mailing Address - State:CA
Mailing Address - Zip Code:91505-3406
Mailing Address - Country:US
Mailing Address - Phone:818-841-0710
Mailing Address - Fax:818-347-4257
Practice Address - Street 1:511 N HOLLYWOOD WAY
Practice Address - Street 2:
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-3406
Practice Address - Country:US
Practice Address - Phone:818-841-0710
Practice Address - Fax:818-347-4257
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA464627363LF0000X
CA11310363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA952662606OtherGRP TAX ID #
CAWNP11310BMedicare ID - Type UnspecifiedMEDICARE #
CAQ61725Medicare UPIN