Provider Demographics
NPI:1639621758
Name:FONDRICK, JASON ALLEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:ALLEN
Last Name:FONDRICK
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 1:3030 NORTH ST STE 430
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77702-1434
Mailing Address - Country:US
Mailing Address - Phone:409-899-2500
Mailing Address - Fax:
Practice Address - Street 1:3030 NORTH ST STE 430
Practice Address - Street 2:
Practice Address - City:BEAUMONT
Practice Address - State:TX
Practice Address - Zip Code:77702-1434
Practice Address - Country:US
Practice Address - Phone:409-899-2500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-10-25
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA10809363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant