Provider Demographics
NPI:1356312482
Name:DOUGLAS, RONALD JASON (PA)
Entity Type:Individual
Prefix:MR
First Name:RONALD
Middle Name:JASON
Last Name:DOUGLAS
Suffix:
Gender:M
Credentials:PA
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Mailing Address - Street 1:PO BOX 80070
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46898-0070
Mailing Address - Country:US
Mailing Address - Phone:260-432-1568
Mailing Address - Fax:260-432-4969
Practice Address - Street 1:5001 US HIGHWAY 30 W STE D
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46818-9701
Practice Address - Country:US
Practice Address - Phone:260-432-1568
Practice Address - Fax:260-432-4969
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2014-11-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
IN10000680A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN981270JJMedicare PIN
P98087Medicare UPIN
INP00068324Medicare PIN