Basic Information
| Provider Information | |||||||||
| NPI: | 1609169903 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MARINOS | ||||||||
| FirstName: | JAMIE | ||||||||
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| Credential: | F.N.P | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 POWELL ST | ||||||||
| Address2: | SUITE 900 | ||||||||
| City: | EMERYVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 946081826 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5103502600 | ||||||||
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| Practice Location | |||||||||
| Address1: | 654 CAMINO DE LOS MARES | ||||||||
| Address2: | |||||||||
| City: | SAN CLEMENTE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926732827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494961122 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/18/2011 | ||||||||
| LastUpdateDate: | 05/18/2011 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 20668 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.