Healthcare Provider Details

I. General information

NPI: 1790865665
Provider Name (Legal Business Name): DR. JASON WAYNE HULL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 06/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 MILLCREEK PLZ
ERIE PA
16565-1102
US

IV. Provider business mailing address

1471 HENDERSONVILLE RD
SANDY LAKE PA
16145-3419
US

V. Phone/Fax

Practice location:
  • Phone: 814-864-4858
  • Fax: 814-864-0398
Mailing address:
  • Phone: 724-376-3785
  • Fax: 814-864-0398

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberPA OEG000291
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: