Provider Demographics
NPI:1093778185
Name:MAXA, JASON (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MAXA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1447 N HARRISON ST
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48602-4727
Mailing Address - Country:US
Mailing Address - Phone:989-583-2794
Mailing Address - Fax:989-583-2829
Practice Address - Street 1:900 COOPER AVE
Practice Address - Street 2:SUITE 3100
Practice Address - City:SAGINAW
Practice Address - State:MI
Practice Address - Zip Code:48602-5182
Practice Address - Country:US
Practice Address - Phone:989-583-7450
Practice Address - Fax:989-583-7452
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2014-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601004158363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIP00256268OtherRAILROAD MEDICARE
MI1093778185Medicaid
MI5731169OtherBCBSM PIN
MIP00256268OtherRAILROAD MEDICARE
MIM74750285Medicare PIN
MI5731169OtherBCBSM PIN