Basic Information
| Provider Information | |||||||||
| NPI: | 1699792523 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FOW | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | E | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1400 E. CHURCH STREET | ||||||||
| Address2: | ATTENTION: MEDICAL STAFF OFFICE | ||||||||
| City: | SANTA MARIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93454 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8057393954 | ||||||||
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| Practice Location | |||||||||
| Address1: | 850 FAIR OAKS AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | ARROYO GRANDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 93420 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8054730700 | ||||||||
| FaxNumber: | 8054735931 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/16/2006 | ||||||||
| LastUpdateDate: | 03/16/2019 | ||||||||
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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 | 207XX0005X | A78523 | CA | N | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine | 207X00000X | A78523 | CA | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery |
ID Information
| ID | Type | State | Issuer | Description | 00A785230 | 01 | BLUE SHIELD PIN | OTHER | 00A785230 | 05 | CA | MEDICAID | 7503617 | 01 | AETNA PIN | OTHER |