Healthcare Provider Details

I. General information

NPI: 1861433393
Provider Name (Legal Business Name): JAKE WATSON JR. PHYSICIAN ASSISTANT
Entity Type: Individual
Gender: Male
Sole Proprietor: X

Provider Other Name: JAKE WATSON JR. PHYSICIAN ASSISTANT

II. Dates (important events)

Enumeration Date: 06/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11301 WILSHIRE BLVD
LOS ANGELES CA
90073-1003
US

IV. Provider business mailing address

3731 S NORTON AVE
LOS ANGELES CA
90018-4046
US

V. Phone/Fax

Practice location:
  • Phone: 310-478-3711
  • Fax:
Mailing address:
  • Phone: 323-296-2388
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number14184
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: