Provider Demographics
NPI:1568600492
Name:RODGERS, JASON ALLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ALLEN
Last Name:RODGERS
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 1:2420 S UNION AVE
Mailing Address - Street 2:STE 200
Mailing Address - City:TACOMA
Mailing Address - State:WA
Mailing Address - Zip Code:98405-1322
Mailing Address - Country:US
Mailing Address - Phone:253-503-2598
Mailing Address - Fax:253-404-0506
Practice Address - Street 1:2202 S CEDAR ST
Practice Address - Street 2:STE 330
Practice Address - City:TACOMA
Practice Address - State:WA
Practice Address - Zip Code:98405-2318
Practice Address - Country:US
Practice Address - Phone:253-272-5127
Practice Address - Fax:253-272-0811
Is Sole Proprietor?:No
Enumeration Date:2009-01-30
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA1124363A00000X
WAPAPA60207408363A00000X
WAPA60207408363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
NVBN227ZOtherMEDICARE PTAN
NV1568600492Medicaid