Provider Demographics
NPI:1891080750
Name:NGUYEN, JENNIFER K (PA-C)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:K
Last Name:NGUYEN
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1466 MARIPOSA STREET
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92114-3612
Mailing Address - Country:US
Mailing Address - Phone:619-777-9423
Mailing Address - Fax:
Practice Address - Street 1:1466 MARIPOSA STREET
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92114-3612
Practice Address - Country:US
Practice Address - Phone:619-777-9423
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-06-17
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21671363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0062450Medicaid
CAW13278Medicare UPIN