Provider Demographics
NPI:1043796402
Name:LU, JONATHAN FAN (FNP-C)
Entity type:Individual
Prefix:
First Name:JONATHAN
Middle Name:FAN
Last Name:LU
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:15000 KENSINGTON PARK DR STE 250
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-1835
Mailing Address - Country:US
Mailing Address - Phone:714-477-8320
Mailing Address - Fax:714-477-8321
Practice Address - Street 1:15000 KENSINGTON PARK DR STE 250
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92782-1835
Practice Address - Country:US
Practice Address - Phone:714-477-8320
Practice Address - Fax:714-477-8321
Is Sole Proprietor?:Yes
Enumeration Date:2018-07-18
Last Update Date:2025-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95009811207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine