Provider Demographics
NPI:1336737840
Name:JORJADZE, KETEVAN (FNP-C)
Entity Type:Individual
Prefix:
First Name:KETEVAN
Middle Name:
Last Name:JORJADZE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3636 5TH AVE
Mailing Address - Street 2:STE 300
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-4230
Mailing Address - Country:US
Mailing Address - Phone:619-814-5500
Mailing Address - Fax:619-794-0260
Practice Address - Street 1:3636 FIFTH AVE STE 300
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-4230
Practice Address - Country:US
Practice Address - Phone:619-814-5500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-01-10
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF346697363LF0000X
CA95017739363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF346697OtherNYS