Provider Demographics
NPI:1184265845
Name:EDENS, JONATHAN (PA)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:EDENS
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 1:8851 RISLEY PL
Mailing Address - Street 2:
Mailing Address - City:GRANITE BAY
Mailing Address - State:CA
Mailing Address - Zip Code:95746-9673
Mailing Address - Country:US
Mailing Address - Phone:707-708-1501
Mailing Address - Fax:
Practice Address - Street 1:9333 TECH CENTER DR STE 100
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95826-2585
Practice Address - Country:US
Practice Address - Phone:916-750-6186
Practice Address - Fax:916-379-7964
Is Sole Proprietor?:No
Enumeration Date:2019-10-03
Last Update Date:2023-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57279363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant