Provider Demographics
NPI:1801028741
Name:HARTMAN, JAYSON C (PAS)
Entity Type:Individual
Prefix:
First Name:JAYSON
Middle Name:C
Last Name:HARTMAN
Suffix:
Gender:M
Credentials:PAS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1100 REID PKWY
Mailing Address - Street 2:MEDICAL STAFF SERVICES
Mailing Address - City:RICHMOND
Mailing Address - State:IN
Mailing Address - Zip Code:47374-1157
Mailing Address - Country:US
Mailing Address - Phone:765-935-8905
Mailing Address - Fax:765-939-4200
Practice Address - Street 1:1400 HIGHLAND RD STE 1
Practice Address - Street 2:
Practice Address - City:RICHMOND
Practice Address - State:IN
Practice Address - Zip Code:47374-8810
Practice Address - Country:US
Practice Address - Phone:765-935-8905
Practice Address - Fax:765-939-4200
Is Sole Proprietor?:No
Enumeration Date:2009-08-11
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50.003006363A00000X
IN10001104A363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000768377OtherANTHEM - REID HOSPITAL
OH0111096Medicaid
OH0111096Medicaid
INM400070751Medicare PIN