Healthcare Provider Details

I. General information

NPI: 1477053767
Provider Name (Legal Business Name): MR. JASON PATRICK PATE I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/14/2018
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1115 W BALBOA BLVD
NEWPORT BEACH CA
92661-1037
US

IV. Provider business mailing address

27893 MAZAGON
MISSION VIEJO CA
92692-1215
US

V. Phone/Fax

Practice location:
  • Phone: 855-271-6289
  • Fax:
Mailing address:
  • Phone: 810-423-8943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374700000X
TaxonomyTechnician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: