Healthcare Provider Details

I. General information

NPI: 1548709983
Provider Name (Legal Business Name): JON UKISHIMA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2017
Last Update Date: 01/06/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 E VALENCIA MESA DR
FULLERTON CA
92835-3809
US

IV. Provider business mailing address

12465 HAZELTINE DR
TUSTIN CA
92782-1139
US

V. Phone/Fax

Practice location:
  • Phone: 714-992-3000
  • Fax:
Mailing address:
  • Phone: 402-850-8380
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number54228
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: