Healthcare Provider Details

I. General information

NPI: 1518574599
Provider Name (Legal Business Name): JONATHAN PERSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/24/2020
Last Update Date: 09/24/2020
Certification Date: 09/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 RACE ST APT 4204
SAN JOSE CA
95126-5155
US

IV. Provider business mailing address

500 RACE ST APT 4204
SAN JOSE CA
95126-5155
US

V. Phone/Fax

Practice location:
  • Phone: 503-875-6267
  • Fax:
Mailing address:
  • Phone: 503-875-6267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code242T00000X
TaxonomyPerfusionist
License Number179068
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: