Healthcare Provider Details

I. General information

NPI: 1750859302
Provider Name (Legal Business Name): MR. JASON MATTHEW JANOIAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/12/2018
Last Update Date: 10/27/2021
Certification Date: 10/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750 DOWNEY AVE STE 308
LAKEWOOD CA
90712-1482
US

IV. Provider business mailing address

PO BOX 15848
NEWPORT BEACH CA
92659-5848
US

V. Phone/Fax

Practice location:
  • Phone: 562-633-3787
  • Fax: 562-633-1977
Mailing address:
  • Phone: 657-241-3600
  • Fax: 657-241-7708

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number56342
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number56342
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: