Provider Demographics
NPI:1689798662
Name:ROLLER, JASON R (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:R
Last Name:ROLLER
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 1:3533 SOUTHERN BLVD
Mailing Address - Street 2:STE 2100
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45429-1267
Mailing Address - Country:US
Mailing Address - Phone:937-395-8556
Mailing Address - Fax:937-522-7873
Practice Address - Street 1:3533 SOUTHERN BLVD
Practice Address - Street 2:STE 2100
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-1267
Practice Address - Country:US
Practice Address - Phone:937-395-8556
Practice Address - Fax:937-522-7873
Is Sole Proprietor?:No
Enumeration Date:2007-03-16
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50-002592363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0080733Medicaid
OH0080733Medicaid
OHH239730Medicare PIN