Provider Demographics
NPI:1083665699
Name:RUNDELL, JASON DOYLE (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DOYLE
Last Name:RUNDELL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Mailing Address - Street 2:9040 JACKSON AVENUE
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98431
Mailing Address - Country:US
Mailing Address - Phone:253-968-1250
Mailing Address - Fax:253-968-3190
Practice Address - Street 1:MADIGAN ARMY MEDICAL CENTER
Practice Address - Street 2:9040 JACKSON AVENUE
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98431
Practice Address - Country:US
Practice Address - Phone:253-968-1250
Practice Address - Fax:253-968-3190
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2019-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA10003162363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8941377OtherL&I
WA8358210Medicaid
WAG8859900Medicare PIN
WAS60416Medicare UPIN
WAG8859902Medicare PIN
WAG8859899Medicare PIN
WAG8871872Medicare PIN
WA8941377OtherL&I
WAG8859903Medicare PIN