Healthcare Provider Details

I. General information

NPI: 1720036213
Provider Name (Legal Business Name): JASON M MAZZA PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 01/09/2024
Certification Date: 01/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 J D ANDERSON DR # A
MORGANTOWN WV
26505-3494
US

IV. Provider business mailing address

1200 J D ANDERSON DR
MORGANTOWN WV
26505-3494
US

V. Phone/Fax

Practice location:
  • Phone: 304-598-1200
  • Fax: 304-598-1699
Mailing address:
  • Phone: 304-598-1200
  • Fax: 304-598-1699

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberWV00975
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: