Provider Demographics
NPI:1659633147
Name:PENG, JASON STEVEN (NP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:STEVEN
Last Name:PENG
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3200 BURNET AVE
Mailing Address - Street 2:3 SOUTH, CENTRAL CREDENTIALING
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45229-3019
Mailing Address - Country:US
Mailing Address - Phone:513-558-5281
Mailing Address - Fax:513-558-5791
Practice Address - Street 1:234 ALBERT SABIN WAY
Practice Address - Street 2:ML 0769
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45267-2827
Practice Address - Country:US
Practice Address - Phone:513-558-5281
Practice Address - Fax:513-558-5791
Is Sole Proprietor?:No
Enumeration Date:2012-06-12
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3012588363L00000X
OHRN.315551163W00000X
OHCOA.13491-NP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0071432Medicaid
KY7100301250Medicaid
OHH113091Medicare PIN