MEDICARE: JEREMY DANIEL BLAKESPEAR P.A.-C.

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	363A00000X	Physician Assistant	51942131206	UT
2	363AM0700X	Medical Physician Assistant	51942131206	UT
3	363A00000X	Physician Assistant	PA 19825	CA

General Provider Information

NPI Number	:	1750474177
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JEREMY DANIEL BLAKESPEAR P.A.-C.

Provider Business Mailing Address
First Line	:	150 VALPREDA RD
Second Line	:
City	:	SAN MARCOS
State	:	CA
Zip	:	92069-2973
Country	:	US
Telephone Number	:	760-736-6767
Fax Number	:

Provider Business Practice Location Address
First Line	:	3220 MISSION AVE STE 1
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92058-1354
Country	:	US
Telephone Number	:	760-433-3155
Fax Number	:

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

Provider Enumeration Date	:	09/30/2006
Last Update Date	:	02/05/2015

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