MEDICARE: JASON VAN TASSEL M.D.

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	207Y00000X	Otolaryngology Physician	A79305	CA

General Provider Information

NPI Number	:	1225143084
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON VAN TASSEL M.D.

Provider Business Mailing Address
First Line	:	2557 MOWRY AVE STE 30
Second Line	:
City	:	FREMONT
State	:	CA
Zip	:	94538-1614
Country	:	US
Telephone Number	:	510-248-1590
Fax Number	:

Provider Business Practice Location Address
First Line	:	2557 MOWRY AVE STE 30
Second Line	:
City	:	FREMONT
State	:	CA
Zip	:	94538-1614
Country	:	US
Telephone Number	:	510-248-1590
Fax Number	:

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

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	09/18/2013

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