Healthcare Provider Details

I. General information

NPI: 1396165288
Provider Name (Legal Business Name): JEFFERSON UY MT ASCP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/18/2014
Last Update Date: 06/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

547 EDINBURGH ST
SAN FRANCISCO CA
94112-2821
US

IV. Provider business mailing address

547 EDINBURGH ST
SAN FRANCISCO CA
94112-2821
US

V. Phone/Fax

Practice location:
  • Phone: 415-312-7730
  • Fax:
Mailing address:
  • Phone: 415-312-7730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246QM0706X
TaxonomyMedical Technologist
License Number09229
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: