Provider Demographics
NPI:1811061237
Name:JASMER, ELLEN LEE (RN, LM, CNM)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:LEE
Last Name:JASMER
Suffix:
Gender:F
Credentials:RN, LM, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16563 DRAPER MINE RD
Mailing Address - Street 2:
Mailing Address - City:SONORA
Mailing Address - State:CA
Mailing Address - Zip Code:95370-8411
Mailing Address - Country:US
Mailing Address - Phone:209-533-2300
Mailing Address - Fax:209-533-4600
Practice Address - Street 1:16563 DRAPER MINE RD
Practice Address - Street 2:
Practice Address - City:SONORA
Practice Address - State:CA
Practice Address - Zip Code:95370-8411
Practice Address - Country:US
Practice Address - Phone:209-533-2300
Practice Address - Fax:209-533-4600
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW1433367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAH205OtherCITY HEALTH PLAN
CANMW014330OtherCA MEDI-CAL PROVIDER #