Basic Information
| Provider Information | |||||||||
| NPI: | 1821089103 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | GWINN | ||||||||
| FirstName: | JANE | ||||||||
| MiddleName: | VANCE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2145 | ||||||||
| Address2: | |||||||||
| City: | SKYLAND | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287762145 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8285752644 | ||||||||
| FaxNumber: | 8283502174 | ||||||||
| Practice Location | |||||||||
| Address1: | 48 CREEKVIEW CT | ||||||||
| Address2: | |||||||||
| City: | GREENVILLE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 296154800 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8644587431 | ||||||||
| FaxNumber: | 8644587463 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/04/2005 | ||||||||
| LastUpdateDate: | 11/16/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2080P0214X | 11118 | SC | Y | Allopathic & Osteopathic Physicians | Pediatrics | Pediatric Pulmonology |
ID Information
| ID | Type | State | Issuer | Description | 111186 | 05 | SC | MEDICAID | AA74976910 | 01 | SC | MEDICARE PTAN | OTHER |