Provider Demographics
NPI:1124473178
Name:LOMHEIM, JASON RYAN (PA-C)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:RYAN
Last Name:LOMHEIM
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 1:7322 YELLOWTAIL DR UNIT 101
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92648-2448
Mailing Address - Country:US
Mailing Address - Phone:714-943-2453
Mailing Address - Fax:
Practice Address - Street 1:2801 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:LONG BEACH
Practice Address - State:CA
Practice Address - Zip Code:90806-1701
Practice Address - Country:US
Practice Address - Phone:714-943-2453
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-27
Last Update Date:2016-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA53761363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical