Healthcare Provider Details

I. General information

NPI: 1255394912
Provider Name (Legal Business Name): JASON CONLEY PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11087 MAIN ST
MARTIN KY
41649-7999
US

IV. Provider business mailing address

PO BOX 910
MARTIN KY
41649-0910
US

V. Phone/Fax

Practice location:
  • Phone: 606-285-0681
  • Fax: 606-285-6619
Mailing address:
  • Phone: 606-285-0681
  • Fax: 606-285-6619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA677
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: