Provider Demographics
NPI:1073794012
Name:AJA, JACOB MANUEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JACOB
Middle Name:MANUEL
Last Name:AJA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 MEDICAL PKWY
Mailing Address - Street 2:SUITE 101
Mailing Address - City:ANNAPOLIS
Mailing Address - State:MD
Mailing Address - Zip Code:21401-3742
Mailing Address - Country:US
Mailing Address - Phone:410-295-8900
Mailing Address - Fax:410-280-4701
Practice Address - Street 1:2000 MEDICAL PKWY
Practice Address - Street 2:SUITE 101
Practice Address - City:ANNAPOLIS
Practice Address - State:MD
Practice Address - Zip Code:21401-3742
Practice Address - Country:US
Practice Address - Phone:410-295-8900
Practice Address - Fax:410-280-4701
Is Sole Proprietor?:No
Enumeration Date:2007-11-19
Last Update Date:2014-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC03809363AS0400X
DCPA030518363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD24609ZDR9Medicare PIN
DC144810ZC78Medicare UPIN
MD148810ZC9BMedicare UPIN
DC247600ZDTRMedicare PIN