Healthcare Provider Details

I. General information

NPI: 1477648590
Provider Name (Legal Business Name): JASON BOVAIR LPN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/04/2006
Last Update Date: 07/09/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23 NORTH RD
SOUTH GLENS FALLS NY
12803-5354
US

IV. Provider business mailing address

23 NORTH RD
SOUTH GLENS FALLS NY
12803-5354
US

V. Phone/Fax

Practice location:
  • Phone: 518-792-7412
  • Fax:
Mailing address:
  • Phone: 518-792-7412
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number00253608
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: