Provider Demographics
NPI:1407422645
Name:SLAVINSKI, GLORIA JIEUN
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:JIEUN
Last Name:SLAVINSKI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:GLORIA
Other - Middle Name:
Other - Last Name:CHOI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1525 256TH ST
Mailing Address - Street 2:
Mailing Address - City:HARBOR CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90710-2733
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1310 CLUB DR
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94592-1187
Practice Address - Country:US
Practice Address - Phone:707-638-5809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-28
Last Update Date:2024-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA98825476F90191Medicaid