Healthcare Provider Details

I. General information

NPI: 1578425054
Provider Name (Legal Business Name): JASON DANIEL BALTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/02/2025
Last Update Date: 12/02/2025
Certification Date: 12/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

637 DUNN RD STE 102A
HAZELWOOD MO
63042-1755
US

IV. Provider business mailing address

2551 BREDELL AVE
MAPLEWOOD MO
63143-1807
US

V. Phone/Fax

Practice location:
  • Phone: 314-831-8600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: