Healthcare Provider Details

I. General information

NPI: 1154859403
Provider Name (Legal Business Name): JONATHAN SCOTT SURFACE MA, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 EL CAMINO REAL
ATHERTON CA
94027-4300
US

IV. Provider business mailing address

680 CEDAR ST APT 6
SAN CARLOS CA
94070-3038
US

V. Phone/Fax

Practice location:
  • Phone: 650-543-3756
  • Fax:
Mailing address:
  • Phone: 530-400-5524
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: