Provider Demographics
NPI:1336481357
Name:RASTOGI-WILSON, GUNJAN (NP)
Entity Type:Individual
Prefix:
First Name:GUNJAN
Middle Name:
Last Name:RASTOGI-WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1939 W CHELTENHAM AVE
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-1046
Mailing Address - Country:US
Mailing Address - Phone:215-884-5715
Mailing Address - Fax:215-884-1442
Practice Address - Street 1:1939 W CHELTENHAM AVE
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-1046
Practice Address - Country:US
Practice Address - Phone:215-884-5715
Practice Address - Fax:215-884-1442
Is Sole Proprietor?:No
Enumeration Date:2013-03-18
Last Update Date:2020-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP012453363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily