Healthcare Provider Details

I. General information

NPI: 1316091051
Provider Name (Legal Business Name): JAMIE LYN STALEY P.A., MPA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 01/03/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 INTERNATIONAL CIR ORTHOPAEDIC DEPARTMENT
SAN JOSE CA
95119-1130
US

IV. Provider business mailing address

41 GRANDVIEW ST #107
SANTA CRUZ CA
95060-3000
US

V. Phone/Fax

Practice location:
  • Phone: 408-363-4531
  • Fax:
Mailing address:
  • Phone: 831-426-2766
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number18352
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: