Provider Demographics
NPI:1730463175
Name:CHAVEZ, JASON DAVID
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:DAVID
Last Name:CHAVEZ
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 1:601 SANDIA VIEW RD NW
Mailing Address - Street 2:
Mailing Address - City:LOS RANCHOS
Mailing Address - State:NM
Mailing Address - Zip Code:87107-5836
Mailing Address - Country:US
Mailing Address - Phone:505-250-0347
Mailing Address - Fax:505-341-9245
Practice Address - Street 1:1111 BARRANCA DR
Practice Address - Street 2:SUITE 700
Practice Address - City:EL PASO
Practice Address - State:TX
Practice Address - Zip Code:79935-5004
Practice Address - Country:US
Practice Address - Phone:915-591-3130
Practice Address - Fax:915-591-3136
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-04
Last Update Date:2011-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM1008207247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other