Provider Demographics
NPI:1679666572
Name:FEDAK, JASON ROBERT (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:ROBERT
Last Name:FEDAK
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 1:2 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANBURY
Mailing Address - State:CT
Mailing Address - Zip Code:06810-8047
Mailing Address - Country:US
Mailing Address - Phone:860-210-1850
Mailing Address - Fax:203-826-2139
Practice Address - Street 1:2 MAIN ST
Practice Address - Street 2:
Practice Address - City:DANBURY
Practice Address - State:CT
Practice Address - Zip Code:06810-8047
Practice Address - Country:US
Practice Address - Phone:203-826-2140
Practice Address - Fax:203-826-2139
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001470363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
290001470CT01OtherANTHEM BCBS
147000OtherCONNECTICARE
2V4615OtherHEALTHNET OF THE NORTHEAS
P3613396OtherOXFORD HEALTH PLANS
970001602Medicare ID - Type Unspecified
290001470CT01OtherANTHEM BCBS