Provider Demographics
NPI:1760854806
Name:WAN, GINA (MSN-ED, RN-BC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:WAN
Suffix:
Gender:F
Credentials:MSN-ED, RN-BC
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:ADRIENNE
Other - Last Name:BETANCOURT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN-ED, RN-BC
Mailing Address - Street 1:5455 S CARDINAL AVE
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85746-2168
Mailing Address - Country:US
Mailing Address - Phone:520-908-5417
Mailing Address - Fax:520-908-5403
Practice Address - Street 1:5455 S CARDINAL AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85746-2168
Practice Address - Country:US
Practice Address - Phone:520-908-5417
Practice Address - Fax:520-908-5403
Is Sole Proprietor?:No
Enumeration Date:2015-10-28
Last Update Date:2015-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN 090641163WS0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WS0200XNursing Service ProvidersRegistered NurseSchool