Provider Demographics
NPI:1689006785
Name:SRA, JASMINE (MD)
Entity Type:Individual
Prefix:
First Name:JASMINE
Middle Name:
Last Name:SRA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8380 W EMILE ZOLA AVE
Mailing Address - Street 2:SUITE 5118
Mailing Address - City:PEORIA
Mailing Address - State:AZ
Mailing Address - Zip Code:85381-4811
Mailing Address - Country:US
Mailing Address - Phone:602-529-4800
Mailing Address - Fax:602-529-4799
Practice Address - Street 1:7200 W BELL RD
Practice Address - Street 2:BLDG E103
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85308-8534
Practice Address - Country:US
Practice Address - Phone:602-529-4800
Practice Address - Fax:602-529-4799
Is Sole Proprietor?:No
Enumeration Date:2013-07-31
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ28089207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ571861Medicaid
AZZ172767Medicare PIN