Provider Demographics
NPI:1417966466
Name:WASHBURN, JON R (PA)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:R
Last Name:WASHBURN
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 11101
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92685-1101
Mailing Address - Country:US
Mailing Address - Phone:866-878-5075
Mailing Address - Fax:
Practice Address - Street 1:525 WEST ACACIA STREET
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95203-2405
Practice Address - Country:US
Practice Address - Phone:209-944-5550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-07
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA15880146D00000X
CA02A5306207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146D00000XEmergency Medical Service ProvidersPersonal Emergency Response Attendant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA15880Medicaid
CA0PA158801Medicare PIN