Provider Demographics
NPI:1376712935
Name:CARTER, JASON ANDREW (MD, MHSA, FACEP)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:ANDREW
Last Name:CARTER
Suffix:
Gender:M
Credentials:MD, MHSA, FACEP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1405 4TH AVE NW
Mailing Address - Street 2:STE 96
Mailing Address - City:ARDMORE
Mailing Address - State:OK
Mailing Address - Zip Code:73401-2708
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1405 4TH AVE NW STE 96
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:OK
Practice Address - Zip Code:73401-2708
Practice Address - Country:US
Practice Address - Phone:417-612-3985
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-27
Last Update Date:2016-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301090607207P00000X
MO2011001438207P00000X, 207PE0004X
TXQ0887207P00000X
OK32576207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1376712935Medicaid
MOO00955428OtherRR MCR
MO440552485OtherTRICARE
MO1376712935Medicaid