Provider Demographics
NPI:1477648590
Name:BOVAIR, JASON (LPN)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BOVAIR
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 NORTH RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH GLENS FALLS
Mailing Address - State:NY
Mailing Address - Zip Code:12803-5354
Mailing Address - Country:US
Mailing Address - Phone:518-792-7412
Mailing Address - Fax:
Practice Address - Street 1:23 NORTH RD
Practice Address - Street 2:
Practice Address - City:SOUTH GLENS FALLS
Practice Address - State:NY
Practice Address - Zip Code:12803-5354
Practice Address - Country:US
Practice Address - Phone:518-792-7412
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-04
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY00253608164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02291770Medicaid