Provider Demographics
NPI:1558594606
Name:GIFFORD, JASON C (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:C
Last Name:GIFFORD
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 1:6006 49TH ST N STE 310
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33709-2149
Mailing Address - Country:US
Mailing Address - Phone:727-527-9779
Mailing Address - Fax:727-522-0415
Practice Address - Street 1:6006 49TH ST N STE 310
Practice Address - Street 2:
Practice Address - City:SAINT PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33709-2149
Practice Address - Country:US
Practice Address - Phone:727-527-9779
Practice Address - Fax:727-522-0415
Is Sole Proprietor?:No
Enumeration Date:2009-08-24
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9110358363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS200617250AMedicaid
KS068002059Medicare PIN