Provider Demographics
NPI:1548402209
Name:JIMENEZ, LOVERNE GREG DE VENECIA (PA-C)
Entity Type:Individual
Prefix:MR
First Name:LOVERNE
Middle Name:GREG DE VENECIA
Last Name:JIMENEZ
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:GREG
Other - Middle Name:
Other - Last Name:JIMENEZ
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PA-C
Mailing Address - Street 1:PO BOX 25608
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84125-0608
Mailing Address - Country:US
Mailing Address - Phone:206-320-4476
Mailing Address - Fax:206-568-7043
Practice Address - Street 1:747 BROADWAY
Practice Address - Street 2:
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98122-4379
Practice Address - Country:US
Practice Address - Phone:206-861-8550
Practice Address - Fax:206-861-8551
Is Sole Proprietor?:No
Enumeration Date:2009-03-27
Last Update Date:2024-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA60061961363AS0400X
TXPA13289363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2000905Medicaid