Healthcare Provider Details

I. General information

NPI: 1225111750
Provider Name (Legal Business Name): JORGE ORTEGA RODRIGUEZ PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 10/06/2022
Certification Date: 10/06/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13975 MONO WAY
SONORA CA
95370-2824
US

IV. Provider business mailing address

PO BOX 939
ANGELS CAMP CA
95222-0939
US

V. Phone/Fax

Practice location:
  • Phone: 209-533-9600
  • Fax:
Mailing address:
  • Phone: 209-754-6262
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA15733
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: