Healthcare Provider Details

I. General information

NPI: 1710525605
Provider Name (Legal Business Name): JESSICA CUELLAR PA-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2019
Last Update Date: 01/23/2021
Certification Date: 01/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4795 MAUREEN CIR
LIVERMORE CA
94550-8016
US

IV. Provider business mailing address

4795 MAUREEN CIR
LIVERMORE CA
94550-8016
US

V. Phone/Fax

Practice location:
  • Phone: 925-337-5460
  • Fax:
Mailing address:
  • Phone: 925-337-5460
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA59064
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: