Provider Demographics
NPI:1043082233
Name:SAN JOSE, MARK JASON JOEL
Entity Type:Individual
Prefix:
First Name:MARK JASON JOEL
Middle Name:
Last Name:SAN JOSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15960 SERENADE LN
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-5076
Mailing Address - Country:US
Mailing Address - Phone:847-222-3113
Mailing Address - Fax:
Practice Address - Street 1:15960 SERENADE LN
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-5076
Practice Address - Country:US
Practice Address - Phone:847-222-3113
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-10-23
Last Update Date:2023-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027777363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care