Provider Demographics
NPI:1598260671
Name:RIES, JACOB WAYNE (PA-C)
Entity Type:Individual
Prefix:
First Name:JACOB
Middle Name:WAYNE
Last Name:RIES
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1140 W LA VETA AVE STE 860
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92868-4218
Mailing Address - Country:US
Mailing Address - Phone:714-835-6500
Mailing Address - Fax:
Practice Address - Street 1:1140 W LA VETA AVE STE 860
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4218
Practice Address - Country:US
Practice Address - Phone:714-835-6500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-29
Last Update Date:2018-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA55464363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical