Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204D00000X | Neuromusculoskeletal Medicine (NMM) | 20A13620 | CA |
N | 207Q00000X | Family Doctor | 20A13620 | CA |
NPI | 1679914469 |
---|---|
Provider Name | Jason Shupe |
First Address | San Dimas, CA 91773-1222 |
Second Address | San Dimas, CA 91773-1222 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/07/2013 |
Last Update Date | 01/12/2021 |