Provider Demographics
NPI:1407632532
Name:SUBA, JACOB RUSSELL
Entity type:Individual
Prefix:
First Name:JACOB
Middle Name:RUSSELL
Last Name:SUBA
Suffix:
Gender:M
Credentials:
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Mailing Address - Street 1:2863 SAINT TROPEZ DR
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91761-0398
Mailing Address - Country:US
Mailing Address - Phone:909-224-0396
Mailing Address - Fax:
Practice Address - Street 1:1120 W LA VETA AVE STE 300
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CA
Practice Address - Zip Code:92868-4246
Practice Address - Country:US
Practice Address - Phone:714-598-1745
Practice Address - Fax:714-941-9539
Is Sole Proprietor?:No
Enumeration Date:2023-09-05
Last Update Date:2025-01-16
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant