Provider Demographics
NPI:1750331948
Name:STABACK, JASON (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:STABACK
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 1:17644 COASTAL HWY #6
Mailing Address - Street 2:
Mailing Address - City:LEWES
Mailing Address - State:DE
Mailing Address - Zip Code:19958
Mailing Address - Country:US
Mailing Address - Phone:877-425-7756
Mailing Address - Fax:
Practice Address - Street 1:17644 COASTAL HWY #6
Practice Address - Street 2:
Practice Address - City:LEWES
Practice Address - State:DE
Practice Address - Zip Code:19958
Practice Address - Country:US
Practice Address - Phone:877-425-7756
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-11
Last Update Date:2023-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MP00051300207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ320525OtherAMERICAID/AMERIGROUP
NJ0161662OtherGHI PPO
NJ3K5491OtherHEALTHNET
NJ081029C2HMedicare PIN
NJP34569Medicare UPIN