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NPI Code Detail

MEDICARE: JASMIN ANN LEASE PA-C

MEDICARE: JASMIN ANN LEASE PA-C
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1363A00000XPhysician AssistantPA-349AR

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
1PA349OTHERARLICENSE

General Provider Information

NPI Number : 1376792457
Entity Type Code : Individual
Provider Name (Legal Business Name) : JASMIN ANN LEASE PA-C
Provider Business Mailing Address
First Line : PO BOX 3250
Second Line :
City : BENTON
State : AR
Zip : 72018-3250
Country : US
Telephone Number : 501-315-0984
Fax Number : 501-847-1405
Provider Business Practice Location Address
First Line : 2010 ACTIVE WAY
Second Line :
City : BENTON
State : AR
Zip : 72019-7566
Country : US
Telephone Number : 501-315-0984
Fax Number : 501-847-1405
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 09/15/2008
Last Update Date : 08/03/2012

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Directions to “ JASMIN ANN LEASE PA-C” Practice Location

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