MEDICARE: JASON ALAN MAXWELL PTA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225200000X	Physical Therapy Assistant	06005269A	IN

General Provider Information

NPI Number	:	1023560638
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON ALAN MAXWELL PTA

Provider Business Mailing Address
First Line	:	7525 MAPLECREST RD # 112
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-1897
Country	:	US
Telephone Number	:	260-273-1206
Fax Number	:

Provider Business Practice Location Address
First Line	:	7525 MAPLECREST RD # 112
Second Line	:
City	:	FORT WAYNE
State	:	IN
Zip	:	46835-1897
Country	:	US
Telephone Number	:	260-273-1206
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/30/2016
Last Update Date	:	10/30/2016

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