Provider Demographics
NPI:1841607363
Name:NALL, JASON M
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:NALL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-6235
Mailing Address - Country:US
Mailing Address - Phone:860-679-3343
Mailing Address - Fax:860-679-4256
Practice Address - Street 1:263 FARMINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:FARMINGTON
Practice Address - State:CT
Practice Address - Zip Code:06030
Practice Address - Country:US
Practice Address - Phone:860-679-3343
Practice Address - Fax:860-679-4256
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3155363AM0700X
CT363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical