Provider Demographics
NPI:1174612170
Name:WU, JONATHAN (PA-C)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:WU
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:PO BOX 722982
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92172-2982
Mailing Address - Country:US
Mailing Address - Phone:858-349-8085
Mailing Address - Fax:
Practice Address - Street 1:7525 METROPOLITAN DR STE 306
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-4404
Practice Address - Country:US
Practice Address - Phone:844-316-7979
Practice Address - Fax:866-813-1235
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2019-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA18550363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA18550OtherPA LICENSE
CAPA18550OtherPA LICENSE
CAWPA18550AMedicare ID - Type Unspecified