Healthcare Provider Details

I. General information

NPI: 1467166546
Provider Name (Legal Business Name): JASON RYAN FELT AG-ACNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2023
Last Update Date: 04/18/2026
Certification Date: 04/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 SAN PABLO ST FL 4
LOS ANGELES CA
90033-5313
US

IV. Provider business mailing address

PO BOX 50938
LOS ANGELES CA
90074-0938
US

V. Phone/Fax

Practice location:
  • Phone: 323-442-7400
  • Fax:
Mailing address:
  • Phone: 323-442-7400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberNP95031072
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN60291550
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: