Provider Demographics
NPI:1609424027
Name:SANTA CRUZ, MATTHEW JORDAN (PA)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JORDAN
Last Name:SANTA CRUZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1234 FOOTHILL BLVD
Mailing Address - Street 2:
Mailing Address - City:LA VERNE
Mailing Address - State:CA
Mailing Address - Zip Code:91750-3329
Mailing Address - Country:US
Mailing Address - Phone:909-971-4808
Mailing Address - Fax:
Practice Address - Street 1:1234 FOOTHILL BLVD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-3329
Practice Address - Country:US
Practice Address - Phone:909-971-4808
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-28
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant