Provider Demographics
NPI:1295109304
Name:VICENCIO, JAN RAYMOND (NP)
Entity type:Individual
Prefix:
First Name:JAN
Middle Name:RAYMOND
Last Name:VICENCIO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:JAN RAYMOND
Other - Middle Name:VICENCIO
Other - Last Name:VICENCIO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:14733 WOODRUFF PL
Mailing Address - Street 2:
Mailing Address - City:BELLFLOWER
Mailing Address - State:CA
Mailing Address - Zip Code:90706-3270
Mailing Address - Country:US
Mailing Address - Phone:562-229-4813
Mailing Address - Fax:
Practice Address - Street 1:2901 W COAST HWY
Practice Address - Street 2:SUITE 200
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-4023
Practice Address - Country:US
Practice Address - Phone:562-229-4813
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-01
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003057363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health