Healthcare Provider Details

I. General information

NPI: 1477093714
Provider Name (Legal Business Name): JENNIFER KAORI FUKASAWA-LARA PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/06/2017
Last Update Date: 11/12/2020
Certification Date: 11/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 N HIGHLAND SPRINGS AVE
BANNING CA
92220-3046
US

IV. Provider business mailing address

38905 VISTA DR
CATHEDRAL CITY CA
92234-2156
US

V. Phone/Fax

Practice location:
  • Phone: 951-845-1121
  • Fax:
Mailing address:
  • Phone: 310-408-9476
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA54259
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: