MEDICARE: MR. JASON R BRAUD LAT

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	390200000X	Student in an Organized Health Care Education/Training Program	AT2539	TX

General Provider Information

NPI Number	:	1952376576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JASON R BRAUD LAT

Provider Business Mailing Address
First Line	:	2911 SAN ROCENDO ST
Second Line	:	APT #4321
City	:	FORT WORTH
State	:	TX
Zip	:	76116-0681
Country	:	US
Telephone Number	:	817-228-4588
Fax Number	:	817-871-3459

Provider Business Practice Location Address
First Line	:	1003 W CANNON ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-3030
Country	:	US
Telephone Number	:	817-871-3435
Fax Number	:	817-871-3459

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

Provider Enumeration Date	:	02/17/2006
Last Update Date	:	07/08/2007

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