Basic Information
| Provider Information | |||||||||
| NPI: | 1215015847 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LA BOURENE | ||||||||
| FirstName: | JAY | ||||||||
| MiddleName: | I. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1550 TIBURON BLVD STE G | ||||||||
| Address2: | |||||||||
| City: | TIBURON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 949202531 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158332000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1550-G TIBURON BLVD | ||||||||
| Address2: | |||||||||
| City: | TIBURON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 94920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4158332000 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2006 | ||||||||
| LastUpdateDate: | 12/04/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208G00000X | G79536 | CA | Y | Allopathic & Osteopathic Physicians | Thoracic Surgery (Cardiothoracic Vascular Surgery) |
ID Information
| ID | Type | State | Issuer | Description | 1225508385 | 01 | CA | NPI-TYPE 2 | OTHER | 00G795360 | 05 | CA | MEDICAID |