Healthcare Provider Details

I. General information

NPI: 1609421007
Provider Name (Legal Business Name): JAIME A MORT FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/03/2019
Last Update Date: 09/26/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43112 15TH ST W
LANCASTER CA
93534-6219
US

IV. Provider business mailing address

1814 MORISAN AVE
PALMDALE CA
93550-7324
US

V. Phone/Fax

Practice location:
  • Phone: 661-729-4487
  • Fax:
Mailing address:
  • Phone: 661-233-1724
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95008554
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: