Provider Demographics
NPI:1417034489
Name:VANETSKY, GARY (PA-C)
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:
Last Name:VANETSKY
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2285 CORPORATE CIR
Mailing Address - Street 2:STE 200
Mailing Address - City:HENDERSON
Mailing Address - State:NV
Mailing Address - Zip Code:89074-7759
Mailing Address - Country:US
Mailing Address - Phone:702-360-2763
Mailing Address - Fax:949-783-2880
Practice Address - Street 1:477 N EL CAMINO REAL
Practice Address - Street 2:C-312
Practice Address - City:ENCINITAS
Practice Address - State:CA
Practice Address - Zip Code:92024-1328
Practice Address - Country:US
Practice Address - Phone:760-436-2300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15456363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical