Provider Demographics
NPI:1619379815
Name:VAN-BRUNT, JASON MICHAEL (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:VAN-BRUNT
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 1:2620 E BARNETT RD
Mailing Address - Street 2:#H
Mailing Address - City:MEDFORD
Mailing Address - State:OR
Mailing Address - Zip Code:97504-8344
Mailing Address - Country:US
Mailing Address - Phone:541-789-4281
Mailing Address - Fax:
Practice Address - Street 1:625 SW RAMSEY AVE
Practice Address - Street 2:SUITE A
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97527-5808
Practice Address - Country:US
Practice Address - Phone:541-472-7956
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-09-18
Last Update Date:2014-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORPA166125363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant