Healthcare Provider Details

I. General information

NPI: 1982640116
Provider Name (Legal Business Name): JASON SQUIRES PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/22/2006
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

698 WESTSIDE DR STE 110
DURANT OK
74701-3085
US

IV. Provider business mailing address

5012 US HWY 75, SUITE 300 ATTN BILLING
DENISON TX
75020-4589
US

V. Phone/Fax

Practice location:
  • Phone:
  • Fax:
Mailing address:
  • Phone: 580-920-1922
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA02526
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: