Healthcare Provider Details

I. General information

NPI: 1184808826
Provider Name (Legal Business Name): JASON G HYSLOP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 12/18/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6699 BEADNELL WAY 237
SAN DIEGO CA
92117-5125
US

IV. Provider business mailing address

6699 BEADNELL WAY 237
SAN DIEGO CA
92117-5125
US

V. Phone/Fax

Practice location:
  • Phone: 916-768-6187
  • Fax:
Mailing address:
  • Phone: 916-768-6187
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247100000X
TaxonomyRadiologic Technologist
License NumberRHF85176
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: