Provider Demographics
NPI:1639119761
Name:DUROSE, JASON K (PAC)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:K
Last Name:DUROSE
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4750 HEMPSTEAD STATION DR
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-5164
Mailing Address - Country:US
Mailing Address - Phone:800-875-0136
Mailing Address - Fax:937-619-4231
Practice Address - Street 1:1275 N HIGH ST
Practice Address - Street 2:
Practice Address - City:HILLSBORO
Practice Address - State:OH
Practice Address - Zip Code:45133-8273
Practice Address - Country:US
Practice Address - Phone:937-393-6100
Practice Address - Fax:937-393-6333
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2009-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001412363A00000X
OH51990569207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
DUPA19363Medicare PIN
P65105Medicare UPIN
OHPA19365Medicare PIN