Healthcare Provider Details

I. General information

NPI: 1376941674
Provider Name (Legal Business Name): JASON LLANES PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2014
Last Update Date: 12/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

718 TENNIE ST
WHARTON TX
77488-2931
US

IV. Provider business mailing address

718 TENNIE ST
WHARTON TX
77488-2931
US

V. Phone/Fax

Practice location:
  • Phone: 832-462-9533
  • Fax:
Mailing address:
  • Phone: 832-462-9533
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2055379
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: