Basic Information
| Provider Information | |||||||||
| NPI: | 1811531502 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | ALARCON-ANAYA | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | ERNESTO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3512 LONE PINE RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975045637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417792003 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3512 LONE PINE RD | ||||||||
| Address2: | |||||||||
| City: | MEDFORD | ||||||||
| State: | OR | ||||||||
| PostalCode: | 975045637 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5417792003 | ||||||||
| FaxNumber: | 5417720147 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2019 | ||||||||
| LastUpdateDate: | 11/05/2019 | ||||||||
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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 | 374700000X | A241902 | OR | Y | Nursing Service Related Providers | Technician |
ID Information
| ID | Type | State | Issuer | Description | 323 | 01 | OR | DADS PROGRAM ON TRACK ROGUE VALLEY | OTHER |