Healthcare Provider Details

I. General information

NPI: 1205812666
Provider Name (Legal Business Name): JASON S URSO REGISTERED PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/19/2005
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 CHURCH ST N
CONCORD NC
28025-2927
US

IV. Provider business mailing address

PO BOX 2000
CONCORD NC
28026-2000
US

V. Phone/Fax

Practice location:
  • Phone: 704-403-1430
  • Fax: 704-403-1158
Mailing address:
  • Phone: 704-403-1430
  • Fax: 704-403-1158

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number0010-02122
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-02122
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: