Provider Demographics
NPI:1578650594
Name:PIERCE, JONATHAN LACEY (MD)
Entity Type:Individual
Prefix:DR
First Name:JONATHAN
Middle Name:LACEY
Last Name:PIERCE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:470 SO AUBURN ST
Mailing Address - Street 2:SUITE E
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945
Mailing Address - Country:US
Mailing Address - Phone:530-273-9992
Mailing Address - Fax:530-273-9998
Practice Address - Street 1:470 SO AUBURN ST
Practice Address - Street 2:SUITE E
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-273-9992
Practice Address - Fax:530-273-9998
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA498360207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
F16533Medicare UPIN
00A498360Medicare ID - Type Unspecified