Provider Demographics
NPI:1134483944
Name:ISSA, JASEN K (PA-C)
Entity Type:Individual
Prefix:
First Name:JASEN
Middle Name:K
Last Name:ISSA
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 1:2001 GLEN ECHO RD
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37215-2807
Mailing Address - Country:US
Mailing Address - Phone:615-292-0012
Mailing Address - Fax:615-279-9997
Practice Address - Street 1:2001 GLEN ECHO RD
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37215-2807
Practice Address - Country:US
Practice Address - Phone:615-292-0012
Practice Address - Fax:615-279-9997
Is Sole Proprietor?:No
Enumeration Date:2012-06-26
Last Update Date:2016-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50003536363A00000X
TN3006363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0072950Medicaid
OH0072950Medicaid