Provider Demographics
NPI:1952967218
Name:URIBE, JONATHAN LUIS (AGACNP)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:LUIS
Last Name:URIBE
Suffix:
Gender:M
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43651 DEVYN LN
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93535-5858
Mailing Address - Country:US
Mailing Address - Phone:818-524-0460
Mailing Address - Fax:
Practice Address - Street 1:1007 W AVENUE M14
Practice Address - Street 2:
Practice Address - City:PALMDALE
Practice Address - State:CA
Practice Address - Zip Code:93551-1443
Practice Address - Country:US
Practice Address - Phone:661-265-7810
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-13
Last Update Date:2019-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95011772363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care