Basic Information
| Provider Information | |||||||||
| NPI: | 1043410871 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERAMISCO | ||||||||
| FirstName: | JAMISON | ||||||||
| MiddleName: | DEREK | ||||||||
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| Credential: | MD PHD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 31566 RAILROAD CANYON ROAD | ||||||||
| Address2: | 2-130 | ||||||||
| City: | CANYON LAKE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925879446 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8778709301 | ||||||||
| FaxNumber: | 8778820462 | ||||||||
| Practice Location | |||||||||
| Address1: | 1125 SIR FRANCIS DRAKE BLVD | ||||||||
| Address2: | |||||||||
| City: | KENTFIELD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94904 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4154569680 | ||||||||
| FaxNumber: | 4154853622 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2007 | ||||||||
| LastUpdateDate: | 07/19/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208D00000X | A105161 | CA | Y | Allopathic & Osteopathic Physicians | General Practice |
No ID Information.