Provider Demographics
NPI:1356816839
Name:BRODY, JASON ROBERT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:ROBERT
Last Name:BRODY
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 1:1576 MERRITT BLVD STE 8
Mailing Address - Street 2:
Mailing Address - City:DUNDALK
Mailing Address - State:MD
Mailing Address - Zip Code:21222-2114
Mailing Address - Country:US
Mailing Address - Phone:443-530-6533
Mailing Address - Fax:
Practice Address - Street 1:1576 MERRITT BLVD STE 8
Practice Address - Street 2:
Practice Address - City:DUNDALK
Practice Address - State:MD
Practice Address - Zip Code:21222-2114
Practice Address - Country:US
Practice Address - Phone:443-530-6533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2022-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC07253363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant