Provider Demographics
NPI:1447290648
Name:GEBALSKI, JAN (PA)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:
Last Name:GEBALSKI
Suffix:
Gender:M
Credentials:PA
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Other - Last Name:
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Mailing Address - Street 1:4551 GLENCOE AVE
Mailing Address - Street 2:SUITE 260
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-6385
Mailing Address - Country:US
Mailing Address - Phone:310-301-2030
Mailing Address - Fax:310-306-5247
Practice Address - Street 1:5974 PENTZ RD
Practice Address - Street 2:EMERGENCY DEPARTMENT
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-5509
Practice Address - Country:US
Practice Address - Phone:530-877-9361
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA11083363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant