Provider Demographics
NPI:1467471045
Name:LOWERY, JASON DAVID (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DAVID
Last Name:LOWERY
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 1:6300 E LAKE BLVD
Mailing Address - Street 2:STE. 301
Mailing Address - City:VANCLEAVE
Mailing Address - State:MS
Mailing Address - Zip Code:39565-6770
Mailing Address - Country:US
Mailing Address - Phone:228-230-2663
Mailing Address - Fax:228-206-1192
Practice Address - Street 1:1720A MEDICAL PARK DR
Practice Address - Street 2:SUITE 220
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-2129
Practice Address - Country:US
Practice Address - Phone:228-392-9533
Practice Address - Fax:228-392-1781
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSPA00070363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00534899Medicaid
Q53656Medicare UPIN
MS00534899Medicaid