Provider Demographics
NPI:1457655938
Name:BOOTH, JAMIE LYNN (PA-C)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:LYNN
Last Name:BOOTH
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JAMIE
Other - Middle Name:LYNN
Other - Last Name:RUNTZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:42126 SWEETSHADE LN
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-3821
Mailing Address - Country:US
Mailing Address - Phone:909-210-3059
Mailing Address - Fax:
Practice Address - Street 1:27300 IRIS AVE
Practice Address - Street 2:
Practice Address - City:MORENO VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92555-4802
Practice Address - Country:US
Practice Address - Phone:951-243-2018
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-27
Last Update Date:2014-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA21124363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant