Provider Demographics
NPI:1619249950
Name:JELEN, GARRY CARROLL (PA-C)
Entity Type:Individual
Prefix:MRS
First Name:GARRY
Middle Name:CARROLL
Last Name:JELEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:45155 RESEARCH PL
Mailing Address - Street 2:SUITE 140
Mailing Address - City:ASHBURN
Mailing Address - State:VA
Mailing Address - Zip Code:20147-4191
Mailing Address - Country:US
Mailing Address - Phone:703-858-0500
Mailing Address - Fax:703-858-5155
Practice Address - Street 1:45155 RESEARCH PL
Practice Address - Street 2:SUITE 140
Practice Address - City:ASHBURN
Practice Address - State:VA
Practice Address - Zip Code:20147-4191
Practice Address - Country:US
Practice Address - Phone:703-858-0500
Practice Address - Fax:703-858-5155
Is Sole Proprietor?:No
Enumeration Date:2012-02-02
Last Update Date:2014-06-02
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0110004520363A00000X
MDC05299363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant