Provider Demographics
NPI:1679628556
Name:LUNSFORD, JASON GARY (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:GARY
Last Name:LUNSFORD
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:PO BOX 30532
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32503-1532
Mailing Address - Country:US
Mailing Address - Phone:850-478-1312
Mailing Address - Fax:850-474-9060
Practice Address - Street 1:1040 GULF BREEZE PKWY
Practice Address - Street 2:SUITE 200
Practice Address - City:GULF BREEZE
Practice Address - State:FL
Practice Address - Zip Code:32561-7809
Practice Address - Country:US
Practice Address - Phone:850-916-3700
Practice Address - Fax:850-916-3710
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
1073878363AM0700X
FLPA9108485363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLY0R57OtherBLUE CROSS BLUE SHIELD
AL172374Medicaid
FL014787900Medicaid
AL593-16867OtherBLUE CROSS BLUE SHIELD
AL172374Medicaid