Provider Demographics
NPI:1821867391
Name:VAN DYKE-GINELL, AUBREY ANN
Entity Type:Individual
Prefix:
First Name:AUBREY
Middle Name:ANN
Last Name:VAN DYKE-GINELL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4150 REGENTS PARK ROW STE 345
Mailing Address - Street 2:
Mailing Address - City:LA JOLLA
Mailing Address - State:CA
Mailing Address - Zip Code:92037-9102
Mailing Address - Country:US
Mailing Address - Phone:858-207-3117
Mailing Address - Fax:
Practice Address - Street 1:4150 REGENTS PARK ROW STE 345
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-9102
Practice Address - Country:US
Practice Address - Phone:858-207-3117
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-12-26
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
CAPA64127363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program