Healthcare Provider Details

I. General information

NPI: 1972934719
Provider Name (Legal Business Name): JONATHAN ENTWISLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/04/2013
Last Update Date: 09/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2452 WATSON CT
PALO ALTO CA
94303-3216
US

IV. Provider business mailing address

2452 WATSON CT
PALO ALTO CA
94303-3216
US

V. Phone/Fax

Practice location:
  • Phone: 650-723-6995
  • Fax:
Mailing address:
  • Phone: 650-723-6995
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number1-107906
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberCRNA95000308
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: