Provider Demographics
NPI:1720113392
Name:RICE, JONATHAN (PAC)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:RICE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:558 SAINT CHARLES DR STE 200
Mailing Address - Street 2:
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-3968
Mailing Address - Country:US
Mailing Address - Phone:805-379-2322
Mailing Address - Fax:805-379-2373
Practice Address - Street 1:558 SAINT CHARLES DR STE 200
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-3968
Practice Address - Country:US
Practice Address - Phone:805-379-2322
Practice Address - Fax:805-379-2373
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2018-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA16576363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical