Healthcare Provider Details

I. General information

NPI: 1205074622
Provider Name (Legal Business Name): RON ALAN MACNUTT PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2009
Last Update Date: 07/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8929 UNIVERSITY CENTER LN SUITE 201
SAN DIEGO CA
92122-1006
US

IV. Provider business mailing address

3750 CONVOY ST STE 201
SAN DIEGO CA
92111-3770
US

V. Phone/Fax

Practice location:
  • Phone: 858-450-4199
  • Fax:
Mailing address:
  • Phone: 858-278-8300
  • Fax: 858-569-1337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA17570
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: