Provider Demographics
NPI:1710651468
Name:PASTRANA, LYANN JASON
Entity Type:Individual
Prefix:
First Name:LYANN JASON
Middle Name:
Last Name:PASTRANA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:CLR-37, 3D MLG
Mailing Address - Street 2:KGAS, UNIT 38404
Mailing Address - City:FPO
Mailing Address - State:AP
Mailing Address - Zip Code:96380-8404
Mailing Address - Country:US
Mailing Address - Phone:415-203-7799
Mailing Address - Fax:
Practice Address - Street 1:KGAS UNIT 38404
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:AP
Practice Address - Zip Code:96380-8404
Practice Address - Country:US
Practice Address - Phone:315-637-2465
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-05
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPA.PA.61470087363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant