Provider Demographics
NPI:1356468979
Name:MOORE, S.JASON (PA)
Entity Type:Individual
Prefix:
First Name:S.JASON
Middle Name:
Last Name:MOORE
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:PO BOX 270596
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-5009
Mailing Address - Country:US
Mailing Address - Phone:970-569-7478
Mailing Address - Fax:970-569-7453
Practice Address - Street 1:181 W MEADOW DR
Practice Address - Street 2:
Practice Address - City:VAIL
Practice Address - State:CO
Practice Address - Zip Code:81657-5242
Practice Address - Country:US
Practice Address - Phone:970-479-5036
Practice Address - Fax:970-569-7453
Is Sole Proprietor?:No
Enumeration Date:2007-03-26
Last Update Date:2008-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2029363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
COCO40128Medicare PIN