Healthcare Provider Details

I. General information

NPI: 1669458519
Provider Name (Legal Business Name): JASON S MAZZA OA-C, CSA, SA-C, OTC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/21/2005
Last Update Date: 09/04/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1745 CITRON CT
TRINITY FL
34655-4902
US

IV. Provider business mailing address

10402 TECOMA DR
TRINITY FL
34655-5049
US

V. Phone/Fax

Practice location:
  • Phone: 727-372-3918
  • Fax:
Mailing address:
  • Phone: 727-372-3918
  • Fax: 727-372-3918

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: