Healthcare Provider Details

I. General information

NPI: 1417097973
Provider Name (Legal Business Name): USN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

34800 BOB WILSON DR NMCSD
SAN DIEGO CA
92134-1098
US

IV. Provider business mailing address

34800 BOB WILSON DR NMCSD
SAN DIEGO CA
92134-1098
US

V. Phone/Fax

Practice location:
  • Phone: 619-532-6666
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name: MS. JOELLE L ANNANDONO
Title or Position: PHYSICIAN ASSISTANT - CERTIFIED
Credential: PA-C
Phone: 619-532-6666