Provider Demographics
NPI:1770838534
Name:THORNBURG, JASON DANIEL (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DANIEL
Last Name:THORNBURG
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 1:400 OVESEN DR
Mailing Address - Street 2:
Mailing Address - City:WILTON
Mailing Address - State:IA
Mailing Address - Zip Code:52778-9612
Mailing Address - Country:US
Mailing Address - Phone:563-732-2121
Mailing Address - Fax:563-732-4232
Practice Address - Street 1:400 OVESEN DR
Practice Address - Street 2:
Practice Address - City:WILTON
Practice Address - State:IA
Practice Address - Zip Code:52778-9612
Practice Address - Country:US
Practice Address - Phone:563-732-2121
Practice Address - Fax:563-732-4232
Is Sole Proprietor?:No
Enumeration Date:2012-07-18
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002312363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
IAIB2621017Medicare PIN