Healthcare Provider Details

I. General information

NPI: 1457606618
Provider Name (Legal Business Name): JASON DOUGLAS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2012
Last Update Date: 08/29/2024
Certification Date: 08/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23401 PRAIRIE STAR PKWY STE B-300
LENEXA KS
66227-7268
US

IV. Provider business mailing address

23401 PRAIRIE STAR PKWY STE B-300
LENEXA KS
66227-7268
US

V. Phone/Fax

Practice location:
  • Phone: 913-677-6319
  • Fax: 913-677-1540
Mailing address:
  • Phone: 913-677-6319
  • Fax: 913-677-1450

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number1501587
License Number StateKS
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number2012021523
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: