Basic Information
| Provider Information | |||||||||
| NPI: | 1205074622 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MACNUTT | ||||||||
| FirstName: | RON | ||||||||
| MiddleName: | ALAN | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3750 CONVOY ST | ||||||||
| Address2: | STE 201 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921113770 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8582788300 | ||||||||
| FaxNumber: | 8585691337 | ||||||||
| Practice Location | |||||||||
| Address1: | 8929 UNIVERSITY CENTER LN | ||||||||
| Address2: | SUITE 201 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921221006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8584504199 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2009 | ||||||||
| LastUpdateDate: | 07/10/2017 | ||||||||
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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 | 363AS0400X | PA17570 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
No ID Information.