Provider Demographics
NPI:1841610953
Name:WACKOWSKI, GILLIAN (DO)
Entity Type:Individual
Prefix:
First Name:GILLIAN
Middle Name:
Last Name:WACKOWSKI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:GILLIAN
Other - Middle Name:ROSALYN
Other - Last Name:HOLLAND
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:937 FRANKLIN BLVD
Mailing Address - Street 2:
Mailing Address - City:LEMOORE
Mailing Address - State:CA
Mailing Address - Zip Code:93246-4700
Mailing Address - Country:US
Mailing Address - Phone:559-998-0889
Mailing Address - Fax:
Practice Address - Street 1:937 FRANKLIN BLVD
Practice Address - Street 2:
Practice Address - City:LEMOORE
Practice Address - State:CA
Practice Address - Zip Code:93246
Practice Address - Country:US
Practice Address - Phone:559-998-0889
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN02004734A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program