Healthcare Provider Details

I. General information

NPI: 1124473178
Provider Name (Legal Business Name): JASON RYAN LOMHEIM PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 09/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2801 ATLANTIC AVE
LONG BEACH CA
90806-1701
US

IV. Provider business mailing address

7322 YELLOWTAIL DR UNIT 101
HUNTINGTON BEACH CA
92648-2448
US

V. Phone/Fax

Practice location:
  • Phone: 714-943-2453
  • Fax:
Mailing address:
  • Phone: 714-943-2453
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number53761
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: