Provider Demographics
NPI:1972720597
Name:DE LA O, JESSE (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSE
Middle Name:
Last Name:DE LA O
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 1:24035 NEWHALL RANCH ROAD
Mailing Address - Street 2:
Mailing Address - City:SANTA CLARITA
Mailing Address - State:CA
Mailing Address - Zip Code:91354
Mailing Address - Country:US
Mailing Address - Phone:661-291-3444
Mailing Address - Fax:
Practice Address - Street 1:24035 NEWHALL RANCH ROAD
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91354-6063
Practice Address - Country:US
Practice Address - Phone:661-291-3444
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-18
Last Update Date:2021-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA 17807363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant