Provider Demographics
NPI:1104338540
Name:STANTON, JEFF EDWARD (CCP)
Entity type:Individual
Prefix:
First Name:JEFF
Middle Name:EDWARD
Last Name:STANTON
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:119 BERENDOS AVE
Mailing Address - Street 2:
Mailing Address - City:PACIFICA
Mailing Address - State:CA
Mailing Address - Zip Code:94044-3109
Mailing Address - Country:US
Mailing Address - Phone:415-713-4591
Mailing Address - Fax:
Practice Address - Street 1:1975 4TH ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94143-2351
Practice Address - Country:US
Practice Address - Phone:415-476-0567
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-25
Last Update Date:2017-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
000063242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist