Provider Demographics
NPI:1285392068
Name:NODA, JASON PRASITSAK (ACNPG-AG)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:PRASITSAK
Last Name:NODA
Suffix:
Gender:M
Credentials:ACNPG-AG
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11370 ANDERSON ST STE 2100
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-3450
Mailing Address - Country:US
Mailing Address - Phone:909-558-2822
Mailing Address - Fax:
Practice Address - Street 1:11370 ANDERSON ST STE 2100
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354
Practice Address - Country:US
Practice Address - Phone:909-558-2822
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-30
Last Update Date:2022-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95016607363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care