Provider Demographics
NPI:1437767589
Name:SUBAYAR, JERONIMO
Entity Type:Individual
Prefix:
First Name:JERONIMO
Middle Name:
Last Name:SUBAYAR
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 1:3715 E CALLE DE RICARDO APT 2
Mailing Address - Street 2:
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92264-1222
Mailing Address - Country:US
Mailing Address - Phone:323-809-0229
Mailing Address - Fax:
Practice Address - Street 1:74923 HOVLEY LN E
Practice Address - Street 2:
Practice Address - City:PALM DESERT
Practice Address - State:CA
Practice Address - Zip Code:92260-1927
Practice Address - Country:US
Practice Address - Phone:760-288-4579
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-07-15
Last Update Date:2020-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA252073164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse