Healthcare Provider Details

I. General information

NPI: 1285803171
Provider Name (Legal Business Name): JASON LEE AUSMUS PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/25/2008
Last Update Date: 10/15/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 SANSOM ST THOMPSON BUILDING, SUITE 239
PHILADELPHIA PA
19107-5002
US

IV. Provider business mailing address

1700 WALNUT ST APT 6F
PHILADELPHIA PA
19103-6000
US

V. Phone/Fax

Practice location:
  • Phone: 215-955-6844
  • Fax:
Mailing address:
  • Phone: 917-971-1017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number011483
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA053388
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: