Healthcare Provider Details

I. General information

NPI: 1871699207
Provider Name (Legal Business Name): JASON E MARIS PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/15/2006
Last Update Date: 03/16/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 MONTLAKE BLVD NE ROOM 148
SEATTLE WA
98195-0001
US

IV. Provider business mailing address

3950 MONTLAKE BLVD NE ROOM 148
SEATTLE WA
98195-0001
US

V. Phone/Fax

Practice location:
  • Phone: 206-543-1552
  • Fax: 206-543-6573
Mailing address:
  • Phone: 206-543-1552
  • Fax: 206-543-6573

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA60310507
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: