Provider Demographics
NPI:1629200894
Name:DELUISA, JASON BEAU (ANP,CNP, APRN)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:BEAU
Last Name:DELUISA
Suffix:
Gender:M
Credentials:ANP,CNP, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15919 29TH ST E
Mailing Address - Street 2:
Mailing Address - City:PARRISH
Mailing Address - State:FL
Mailing Address - Zip Code:34219-1854
Mailing Address - Country:US
Mailing Address - Phone:505-331-0295
Mailing Address - Fax:907-865-2433
Practice Address - Street 1:15919 29TH ST E
Practice Address - Street 2:
Practice Address - City:PARRISH
Practice Address - State:FL
Practice Address - Zip Code:34219-1854
Practice Address - Country:US
Practice Address - Phone:505-331-0295
Practice Address - Fax:907-865-2433
Is Sole Proprietor?:No
Enumeration Date:2009-08-20
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK117659363LF0000X, 363LP0808X
NMCNP-01518363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AK1666771Medicaid
NM37805771Medicaid
NM37805771Medicaid