Provider Demographics
NPI:1073383857
Name:SAN LUIS, JONATHAN ALLEN
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ALLEN
Last Name:SAN LUIS
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 1:8710 MONROE CT STE 200
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4884
Mailing Address - Country:US
Mailing Address - Phone:909-481-9515
Mailing Address - Fax:
Practice Address - Street 1:8710 MONROE CT STE 200
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4884
Practice Address - Country:US
Practice Address - Phone:909-481-9515
Practice Address - Fax:909-481-9520
Is Sole Proprietor?:No
Enumeration Date:2024-01-03
Last Update Date:2024-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95028524363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner