Provider Demographics
NPI:1164889317
Name:WITZEL, JASON (CRNA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:WITZEL
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:107 CORRAL WAY APT A
Mailing Address - Street 2:
Mailing Address - City:DODGE CITY
Mailing Address - State:KS
Mailing Address - Zip Code:67801-7253
Mailing Address - Country:US
Mailing Address - Phone:205-585-1301
Mailing Address - Fax:
Practice Address - Street 1:107 CORRAL WAY APT A
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-7253
Practice Address - Country:US
Practice Address - Phone:205-585-1301
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-19
Last Update Date:2016-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS43-557387-122367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered