Provider Demographics
NPI:1619208618
Name:RAEHL, JASON L (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:RAEHL
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 1:269 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97520-1551
Mailing Address - Country:US
Mailing Address - Phone:541-482-4533
Mailing Address - Fax:
Practice Address - Street 1:269 MAPLE ST
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OR
Practice Address - Zip Code:97520-1551
Practice Address - Country:US
Practice Address - Phone:541-482-4533
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-01-15
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4602363A00000X
NH0765363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIM74460852Medicare PIN