MEDICARE: JONATHAN RICE PAC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363AS0400X	Surgical Physician Assistant	PA16576	CA

General Provider Information

NPI Number	:	1720113392
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN RICE PAC

Provider Business Mailing Address
First Line	:	558 SAINT CHARLES DR STE 200
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-3968
Country	:	US
Telephone Number	:	805-379-2322
Fax Number	:	805-379-2373

Provider Business Practice Location Address
First Line	:	558 SAINT CHARLES DR STE 200
Second Line	:
City	:	THOUSAND OAKS
State	:	CA
Zip	:	91360-3968
Country	:	US
Telephone Number	:	805-379-2322
Fax Number	:	805-379-2373

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2007
Last Update Date	:	04/26/2018

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Directions to “ JONATHAN RICE PAC” Practice Location

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