Provider Demographics
NPI:1417022013
Name:JANCZYK, GWEN S (PA)
Entity Type:Individual
Prefix:MRS
First Name:GWEN
Middle Name:S
Last Name:JANCZYK
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:GWEN
Other - Middle Name:S
Other - Last Name:WHITEHEAD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
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:858-824-5353
Mailing Address - Fax:
Practice Address - Street 1:9898 GENESEE AVE
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1205
Practice Address - Country:US
Practice Address - Phone:858-824-5353
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2020-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15930363AM0700X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
P68411Medicare UPIN
CAWPA15930AMedicare PIN