Provider Demographics
NPI:1467566463
Name:TRUSTY, JASON CLONNIE (PA C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:CLONNIE
Last Name:TRUSTY
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 1:208 MACCORKLE AVE SE
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:WV
Mailing Address - Zip Code:25314-1160
Mailing Address - Country:US
Mailing Address - Phone:304-343-4300
Mailing Address - Fax:304-343-5476
Practice Address - Street 1:208 MACCORKLE AVE SE
Practice Address - Street 2:
Practice Address - City:CHARLESTON
Practice Address - State:WV
Practice Address - Zip Code:25314-1160
Practice Address - Country:US
Practice Address - Phone:304-343-4300
Practice Address - Fax:304-343-5476
Is Sole Proprietor?:No
Enumeration Date:2006-08-18
Last Update Date:2010-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV01157363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
Q57756Medicare UPIN
TRPA26013Medicare ID - Type UnspecifiedPARKERSBURG, WV OFFICE
TRPA26014Medicare ID - Type UnspecifiedRIPLEY WV OFFICE
TRPA26015Medicare ID - Type UnspecifiedLOGAN WV OFFICE
TRPA26011Medicare ID - Type UnspecifiedBECKLEY WV OFFICE
TRPA26012Medicare ID - Type UnspecifiedCHARLESTON, WV OFFICE