Healthcare Provider Details

I. General information

NPI: 1124360839
Provider Name (Legal Business Name): JESSE DANIEL HOAGLAND PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2013
Last Update Date: 06/25/2025
Certification Date: 06/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

808 W 58TH ST
LOS ANGELES CA
90037-3632
US

IV. Provider business mailing address

808 W 58TH ST
LOS ANGELES CA
90037-3632
US

V. Phone/Fax

Practice location:
  • Phone: 323-541-1411
  • Fax:
Mailing address:
  • Phone: 323-541-1411
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number52657
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: