=====================================================
General NPI Number Information
=====================================================
NPI Number | 1033540554
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JASON UNRUH PA-C
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/09/2013
-----------------------------------------------------
Last Update Date | 01/08/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3812 BERNICE DR
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92107-2702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-861-9759
-----------------------------------------------------
Fax | 619-684-3790
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 99087
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92169-1087
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-861-9759
-----------------------------------------------------
Fax | 619-684-3790
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363AM0700X
-----------------------------------------------------
Taxonomy Name | Medical Physician Assistant
-----------------------------------------------------
License Number | 21321
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 21321
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------