Basic Information
| Provider Information | |||||||||
| NPI: | 1255619789 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MAN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | PAUL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 10470 OLD PLACERVILLE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958272539 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8004700071 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2800 L ST FL 6 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958165616 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9168874040 | ||||||||
| FaxNumber: | 9168874045 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2011 | ||||||||
| LastUpdateDate: | 01/22/2019 | ||||||||
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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 | 390200000X | MT200414 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RC0001X | MT200414 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology | 207RC0001X | C159950 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Clinical Cardiac Electrophysiology |
ID Information
| ID | Type | State | Issuer | Description | 871559 | 05 | AZ | MEDICAID |