=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073892212
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | AMI JINESH PATEL PA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/05/2011
-----------------------------------------------------
Last Update Date | 12/14/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 9961 SIERRA AVE
-----------------------------------------------------
City | FONTANA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92335
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-427-7242
-----------------------------------------------------
Fax | 909-427-4620
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 204 SAINT CATHERINE ST
-----------------------------------------------------
City | REDLANDS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92374-8245
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-794-3735
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 50.002867
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | 011008
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363A00000X
-----------------------------------------------------
Taxonomy Name | Physician Assistant
-----------------------------------------------------
License Number | PA19824
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------