Provider Demographics
NPI:1497849939
Name:COSSEY, JASON LEE (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:LEE
Last Name:COSSEY
Suffix:
Gender:M
Credentials:PA
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-9200
Mailing Address - Fax:704-384-6588
Practice Address - Street 1:1450 MATTHEWS TOWNSHIP PKWY STE 380
Practice Address - Street 2:
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105
Practice Address - Country:US
Practice Address - Phone:704-384-9200
Practice Address - Fax:704-384-6588
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2020-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY008285363A00000X
NC0010-06364363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02565520Medicaid
NY02565520Medicaid