Provider Demographics
NPI:1356404305
Name:JASSO, MICHAEL D (PA)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
Last Name:JASSO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16008 KAMANA RD
Mailing Address - Street 2:STE 100
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-1376
Mailing Address - Country:US
Mailing Address - Phone:760-956-5200
Mailing Address - Fax:760-669-0793
Practice Address - Street 1:16008 KAMANA RD
Practice Address - Street 2:STE 100
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-1376
Practice Address - Country:US
Practice Address - Phone:760-956-5200
Practice Address - Fax:760-669-0793
Is Sole Proprietor?:No
Enumeration Date:2006-12-19
Last Update Date:2021-11-03
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAPA18645363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18645OtherPHYSCIAN ASSISTAN LIC