Provider Demographics
NPI:1003450214
Name:DE JESUS, CHRISTIANA (PA-C)
Entity type:Individual
Prefix:
First Name:CHRISTIANA
Middle Name:
Last Name:DE JESUS
Suffix:
Gender:F
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 1:770 MAGNOLIA AVE STE 2A
Mailing Address - Street 2:
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92879-3122
Mailing Address - Country:US
Mailing Address - Phone:951-736-8144
Mailing Address - Fax:
Practice Address - Street 1:1362 GLENTHORPE DR
Practice Address - Street 2:
Practice Address - City:WALNUT
Practice Address - State:CA
Practice Address - Zip Code:91789-3858
Practice Address - Country:US
Practice Address - Phone:909-576-7810
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-30
Last Update Date:2019-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA57162363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant