MEDICARE: MR. JASON SCOTT WALLACE 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	AT5146	CA

General Provider Information

NPI Number	:	1891786646
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON SCOTT WALLACE PTA

Provider Business Mailing Address
First Line	:	4979 BURSON WAY
Second Line	:
City	:	OXNARD
State	:	CA
Zip	:	93036-1017
Country	:	US
Telephone Number	:	805-671-5625
Fax Number	:

Provider Business Practice Location Address
First Line	:	2486 N PONDEROSA DR
Second Line	:	STE D-106
City	:	CAMARILLO
State	:	CA
Zip	:	93010-2376
Country	:	US
Telephone Number	:	805-484-5447
Fax Number	:

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

Provider Enumeration Date	:	11/01/2005
Last Update Date	:	07/08/2007

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