Healthcare Provider Details

I. General information

NPI: 1023352481
Provider Name (Legal Business Name): JONAS CARULLO SABLAN AGNP-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/23/2012
Last Update Date: 12/11/2025
Certification Date: 12/11/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1069 AZURE CT
PALM SPRINGS CA
92262-2370
US

IV. Provider business mailing address

1069 AZURE CT
PALM SPRINGS CA
92262-2370
US

V. Phone/Fax

Practice location:
  • Phone: 573-694-6658
  • Fax:
Mailing address:
  • Phone: 573-694-6658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number95037512
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: