Provider Demographics
NPI:1689343402
Name:RUTT, JONATHON CHRISTOPHER (PA-C)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:CHRISTOPHER
Last Name:RUTT
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 1:1847 W HEATHERBRAE DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85015-4764
Mailing Address - Country:US
Mailing Address - Phone:602-274-2100
Mailing Address - Fax:602-535-3166
Practice Address - Street 1:1847 W HEATHERBRAE DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85015-4764
Practice Address - Country:US
Practice Address - Phone:602-274-2100
Practice Address - Fax:602-535-3166
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ8596363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ8596OtherARIZONA REGULATORY BOARD OF PHYSICIAN ASSISTANT