Provider Demographics
NPI:1235122961
Name:RUIZ, JOSE LUIS (PA)
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:RUIZ
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 232410
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92193-2410
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9400 CAMPUS POINT DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92093
Practice Address - Country:US
Practice Address - Phone:858-657-7876
Practice Address - Fax:858-249-3850
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2018-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA14782363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA14782OtherPA LICENSE
CAS98887Medicare UPIN