Healthcare Provider Details

I. General information

NPI: 1316117930
Provider Name (Legal Business Name): JASON R SOUTHALL PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 08/06/2025
Certification Date: 08/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 STONECREST DR
HUNTINGTON WV
25701-9391
US

IV. Provider business mailing address

2 STONECREST DR
HUNTINGTON WV
25701-9391
US

V. Phone/Fax

Practice location:
  • Phone: 304-525-2273
  • Fax: 304-525-2165
Mailing address:
  • Phone: 304-525-2273
  • Fax: 304-525-2165

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number01257
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: