Provider Demographics
NPI:1538190590
Name:VITZTHUM, GINA (NP)
Entity type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:VITZTHUM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:351 HOSPITAL RD
Mailing Address - Street 2:SUITE 401
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92663-3509
Mailing Address - Country:US
Mailing Address - Phone:949-642-6787
Mailing Address - Fax:949-642-4833
Practice Address - Street 1:351 HOSPITAL RD
Practice Address - Street 2:SUITE 401
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92663-3509
Practice Address - Country:US
Practice Address - Phone:949-642-6787
Practice Address - Fax:949-642-4833
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP12701363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WNP12701AMedicare ID - Type Unspecified