Provider Demographics
NPI:1609636844
Name:JANSEN VAN RENSBURG, PETRUS JOHANNES
Entity Type:Individual
Prefix:
First Name:PETRUS
Middle Name:JOHANNES
Last Name:JANSEN VAN RENSBURG
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 BOLINAS AVE
Mailing Address - Street 2:
Mailing Address - City:ROSS
Mailing Address - State:CA
Mailing Address - Zip Code:94957-9644
Mailing Address - Country:US
Mailing Address - Phone:628-888-4354
Mailing Address - Fax:
Practice Address - Street 1:4650 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-6062
Practice Address - Country:US
Practice Address - Phone:628-888-4354
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-03-21
Last Update Date:2024-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program