Provider Demographics
NPI:1376567933
Name:WACHOWIAK, JEIMA PATACSIL (NP, PHN, RN)
Entity Type:Individual
Prefix:
First Name:JEIMA
Middle Name:PATACSIL
Last Name:WACHOWIAK
Suffix:
Gender:F
Credentials:NP, PHN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 W GONZALES RD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:OXNARD
Mailing Address - State:CA
Mailing Address - Zip Code:93036-3072
Mailing Address - Country:US
Mailing Address - Phone:805-983-0691
Mailing Address - Fax:805-983-2026
Practice Address - Street 1:1200 W GONZALES RD
Practice Address - Street 2:SUITE 300
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93036-3072
Practice Address - Country:US
Practice Address - Phone:805-983-0691
Practice Address - Fax:805-983-2026
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA524153363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA524153Medicaid
CAZZZ75566ZMedicaid
CAZZZ34679ZOtherBLUE CROSS
CAZZZ34679ZOtherBLUE CROSS