Basic Information
| Provider Information | |||||||||
| NPI: | 1497370514 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BECKER | ||||||||
| FirstName: | JANTIMA | ||||||||
| MiddleName: | SHANNON | ||||||||
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| Credential: | PA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1060 CROSSWATER DR | ||||||||
| Address2: | |||||||||
| City: | RENO | ||||||||
| State: | NV | ||||||||
| PostalCode: | 895237100 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7753545457 | ||||||||
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| Practice Location | |||||||||
| Address1: | 9850 GENESEE AVE STE 320 | ||||||||
| Address2: | |||||||||
| City: | LA JOLLA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 920371208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8585541212 | ||||||||
| FaxNumber: | 8587951195 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/15/2020 | ||||||||
| LastUpdateDate: | 02/07/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 02/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.