Provider Demographics
NPI:1942963491
Name:RUEDA, MARK JUSTIN JARABA (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MARK JUSTIN
Middle Name:JARABA
Last Name:RUEDA
Suffix:
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1007 HARRINGTON WAY
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-1021
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1007 HARRINGTON WAY
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-1021
Practice Address - Country:US
Practice Address - Phone:714-883-6264
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-20
Last Update Date:2021-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018894363LG0600X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology