Provider Demographics
NPI:1821123803
Name:RUNYAN, JASON (NP)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:RUNYAN
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13927 SHIPWRECK CIR N
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32224-1121
Mailing Address - Country:US
Mailing Address - Phone:904-570-9404
Mailing Address - Fax:904-379-9332
Practice Address - Street 1:13927 SHIPWRECK CIR N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32224-1121
Practice Address - Country:US
Practice Address - Phone:904-570-9404
Practice Address - Fax:904-379-9332
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2017-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9334592363L00000X
KY4425P363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
000000548409OtherBCBS
KY3548051000OtherPASSPORT ADVANTAGE
000000548409OtherBCBS