Provider Demographics
NPI:1568176063
Name:BULATAO, JASON ADRIAN ALONSO
Entity Type:Individual
Prefix:
First Name:JASON ADRIAN
Middle Name:ALONSO
Last Name:BULATAO
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 1:200 PINE AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90802-3039
Mailing Address - Country:US
Mailing Address - Phone:714-400-1781
Mailing Address - Fax:
Practice Address - Street 1:200 PINE AVE STE 400
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90802-3039
Practice Address - Country:US
Practice Address - Phone:714-400-1781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-09
Last Update Date:2023-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA21522747OtherKAISER PERMANENTE