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General NPI Number Information
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NPI Number | 1861637274
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Entity Type | Individual
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Provider Name | JASON KENNETH AGUSTIN PA-C
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Gender | Male
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Dates
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Enumeration Date | 12/15/2008
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Last Update Date | 05/05/2023
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Provider Practice Location Address
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Address Line | 136 BRIDGE ST
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City | SAN GABRIEL
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State | CA
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Zip | 91775-2720
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Country | US
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Telephone | 562-833-0184
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Fax |
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Provider Business Mailing Address
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Address Line | 136 BRIDGE ST
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City | SAN GABRIEL
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State | CA
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Zip | 91775-2720
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Country | US
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Telephone | 562-833-0184
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AM0700X
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Taxonomy Name | Medical Physician Assistant
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License Number | PA20040
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License Number State | CA
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