Provider Demographics
NPI:1790352185
Name:SNYDER, JASON OWEN (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:OWEN
Last Name:SNYDER
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11333 S 1000 E STE 102
Mailing Address - Street 2:
Mailing Address - City:SANDY
Mailing Address - State:UT
Mailing Address - Zip Code:84094-5421
Mailing Address - Country:US
Mailing Address - Phone:801-462-2205
Mailing Address - Fax:
Practice Address - Street 1:11333 S 1000 E STE 102
Practice Address - Street 2:
Practice Address - City:SANDY
Practice Address - State:UT
Practice Address - Zip Code:84094-5421
Practice Address - Country:US
Practice Address - Phone:801-462-2205
Practice Address - Fax:801-748-1030
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-05
Last Update Date:2022-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
UT12234294-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program