Provider Demographics
NPI:1942654280
Name:FANSELAU, JASON (CNIM)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:FANSELAU
Suffix:
Gender:M
Credentials:CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 W 13TH ST
Mailing Address - Street 2:APT 1011
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64105-1726
Mailing Address - Country:US
Mailing Address - Phone:972-489-6170
Mailing Address - Fax:
Practice Address - Street 1:128 W 13TH ST
Practice Address - Street 2:APT 1011
Practice Address - City:KANSAS CITY
Practice Address - State:MO
Practice Address - Zip Code:64105-1726
Practice Address - Country:US
Practice Address - Phone:972-489-6170
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-22
Last Update Date:2016-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic