Provider Demographics
NPI:1750342895
Name:FENSKE, GINA L (PAC)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:L
Last Name:FENSKE
Suffix:
Gender:F
Credentials:PAC
Other - Prefix:
Other - First Name:GINA
Other - Middle Name:L
Other - Last Name:WOOD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:7300 N FRESNO ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2941
Mailing Address - Country:US
Mailing Address - Phone:209-725-7149
Mailing Address - Fax:209-726-0134
Practice Address - Street 1:374 W OLIVE AVE
Practice Address - Street 2:SUITE A
Practice Address - City:MERCED
Practice Address - State:CA
Practice Address - Zip Code:95348-3181
Practice Address - Country:US
Practice Address - Phone:209-384-5766
Practice Address - Fax:209-383-4230
Is Sole Proprietor?:No
Enumeration Date:2006-03-29
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15207363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA053992Medicaid
P56645Medicare UPIN
CA05-1304Medicare ID - Type UnspecifiedLISCENCE NUMBER