Provider Demographics
NPI:1376792457
Name:LEASE, JASMIN ANN (PA-C)
Entity Type:Individual
Prefix:
First Name:JASMIN
Middle Name:ANN
Last Name:LEASE
Suffix:
Gender:F
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:PO BOX 3250
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-3250
Mailing Address - Country:US
Mailing Address - Phone:501-315-0984
Mailing Address - Fax:501-847-1405
Practice Address - Street 1:2010 ACTIVE WAY
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72019-7566
Practice Address - Country:US
Practice Address - Phone:501-315-0984
Practice Address - Fax:501-847-1405
Is Sole Proprietor?:No
Enumeration Date:2008-09-15
Last Update Date:2012-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARPA-349363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ARPA349OtherLICENSE
ARPA349OtherLICENSE