Provider Demographics
NPI:1396891321
Name:ROY, JONATHAN PETER (PA-C)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:PETER
Last Name:ROY
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 1:12408 HESPERIA RD STE 2
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92395-4786
Mailing Address - Country:US
Mailing Address - Phone:760-952-1222
Mailing Address - Fax:760-952-1073
Practice Address - Street 1:12408 HESPERIA RD STE 2
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92395-4786
Practice Address - Country:US
Practice Address - Phone:760-952-1222
Practice Address - Fax:760-952-1073
Is Sole Proprietor?:No
Enumeration Date:2007-01-25
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA17660363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1396891321Medicaid