Provider Demographics
NPI:1922052539
Name:STOTTLEMYER, JAN K (PA)
Entity Type:Individual
Prefix:
First Name:JAN
Middle Name:K
Last Name:STOTTLEMYER
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 DUTCH LN
Mailing Address - Street 2:
Mailing Address - City:PENNGROVE
Mailing Address - State:CA
Mailing Address - Zip Code:94951-9717
Mailing Address - Country:US
Mailing Address - Phone:561-635-0956
Mailing Address - Fax:
Practice Address - Street 1:101 CASA BUENA DR
Practice Address - Street 2:
Practice Address - City:CORTE MADERA
Practice Address - State:CA
Practice Address - Zip Code:94925-1762
Practice Address - Country:US
Practice Address - Phone:561-635-0956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-19
Last Update Date:2024-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA3632363AM0700X
CA58964363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS85629Medicare UPIN