Healthcare Provider Details

I. General information

NPI: 1639119761
Provider Name (Legal Business Name): JASON K DUROSE PAC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2006
Last Update Date: 11/06/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 N HIGH ST
HILLSBORO OH
45133-8273
US

IV. Provider business mailing address

4750 HEMPSTEAD STATION DR
KETTERING OH
45429-5164
US

V. Phone/Fax

Practice location:
  • Phone: 937-393-6100
  • Fax: 937-393-6333
Mailing address:
  • Phone: 800-875-0136
  • Fax: 937-619-4231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number50001412
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number51990569
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: