Provider Demographics
NPI:1790426229
Name:WALTERS, JASON (OWNER)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:WALTERS
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 LEROY PL # AT22
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-3660
Mailing Address - Country:US
Mailing Address - Phone:845-375-5545
Mailing Address - Fax:
Practice Address - Street 1:51 LEROY PL # AT22
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-3660
Practice Address - Country:US
Practice Address - Phone:845-375-5545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-06
Last Update Date:2022-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY611471496343900000X
NY611417496343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)