Provider Demographics
NPI:1154859403
Name:SURFACE, JONATHAN SCOTT (MA, ATC)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:SCOTT
Last Name:SURFACE
Suffix:
Gender:M
Credentials:MA, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:680 CEDAR ST APT 6
Mailing Address - Street 2:
Mailing Address - City:SAN CARLOS
Mailing Address - State:CA
Mailing Address - Zip Code:94070-3038
Mailing Address - Country:US
Mailing Address - Phone:530-400-5524
Mailing Address - Fax:
Practice Address - Street 1:1000 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:ATHERTON
Practice Address - State:CA
Practice Address - Zip Code:94027-4300
Practice Address - Country:US
Practice Address - Phone:650-543-3756
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA2255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer