Healthcare Provider Details

I. General information

NPI: 1235188145
Provider Name (Legal Business Name): RONNIE JAY ESCUDERO P.A.-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: RON ESCUDERO P.A.-C

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4647 ZION AVE KAISER PERMANENTE; DEPARTMENT OF ORTHOPEDIC SURGERY
SAN DIEGO CA
92120-2507
US

IV. Provider business mailing address

4647 ZION AVE KAISER PERMANENTE; DEPARTMENT OF ORTHOPEDIC SURGERY
SAN DIEGO CA
92120-2507
US

V. Phone/Fax

Practice location:
  • Phone: 866-459-2912
  • Fax:
Mailing address:
  • Phone: 866-459-2912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA17099
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: