Healthcare Provider Details

I. General information

NPI: 1457934408
Provider Name (Legal Business Name): JASON KONSTANTIN TRENT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JASON KONSTATIN TRENT MD

II. Dates (important events)

Enumeration Date: 04/28/2021
Last Update Date: 04/28/2021
Certification Date: 04/28/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

464 LUCE AVE
UKIAH CA
95482-5631
US

IV. Provider business mailing address

464 LUCE AVE
UKIAH CA
95482-5631
US

V. Phone/Fax

Practice location:
  • Phone: 707-463-1578
  • Fax:
Mailing address:
  • Phone: 707-463-1578
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License NumberC-3243
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZF0201X
TaxonomyForensic Pathology Physician
License NumberMD-1858
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: