MEDICARE: JASON TODD WILLETTE P.T.A.

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	A-0453	NV

General Provider Information

NPI Number	:	1407140130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JASON TODD WILLETTE P.T.A.

Provider Business Mailing Address
First Line	:	6900 N DURANGO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-4409
Country	:	US
Telephone Number	:	702-629-1371
Fax Number	:	702-629-1627

Provider Business Practice Location Address
First Line	:	6900 N DURANGO DR
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89149-4409
Country	:	US
Telephone Number	:	702-629-1371
Fax Number	:	702-629-1627

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

Provider Enumeration Date	:	05/28/2011
Last Update Date	:	05/28/2011

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