Healthcare Provider Details

I. General information

NPI: 1396709150
Provider Name (Legal Business Name): JASON H WARDELL PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/17/2006
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10301 KANIS RD
LITTLE ROCK AR
72205-6205
US

IV. Provider business mailing address

10301 KANIS RD
LITTLE ROCK AR
72205-6205
US

V. Phone/Fax

Practice location:
  • Phone: 501-604-6900
  • Fax: 501-604-6941
Mailing address:
  • Phone: 501-604-6900
  • Fax: 501-604-6941

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA235
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA235
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA235
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: