Provider Demographics
NPI:1861895781
Name:SAN JUAN, REUBEN (PA-C)
Entity type:Individual
Prefix:
First Name:REUBEN
Middle Name:
Last Name:SAN JUAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7774 CHERRY AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4014
Mailing Address - Country:US
Mailing Address - Phone:909-355-1296
Mailing Address - Fax:
Practice Address - Street 1:7774 CHERRY AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-4014
Practice Address - Country:US
Practice Address - Phone:909-355-1296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-06
Last Update Date:2014-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA52028363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical