Healthcare Provider Details

I. General information

NPI: 1417228909
Provider Name (Legal Business Name): JASON FORT CST/CSA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2012
Last Update Date: 08/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2778 E SUPERIOR RD
SAN TAN VALLEY AZ
85143-4573
US

IV. Provider business mailing address

2778 E SUPERIOR RD
SAN TAN VALLEY AZ
85143-4573
US

V. Phone/Fax

Practice location:
  • Phone: 480-313-9045
  • Fax: 480-987-2186
Mailing address:
  • Phone: 480-313-9045
  • Fax: 480-987-2186

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License Number454110172
License Number StateOR
# 2
Primary TaxonomyY
Taxonomy Code246ZS0410X
TaxonomySurgical Technologist
License NumberL18709787
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: