| NPI | 1053072173 |
|---|---|
| Former Name | JENNY ANNE VAN WAGONER |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363A00000X Physician Assistant (Licence: NC 0010-14138) |
| Additional Taxonomies | 363AM0700X Physician Assistant, Medical (Licence: NC 0010-14138) |
| Enumeration Date | 2022-01-02 |
| Last Update Date | 2025-04-24 |