Provider Demographics
NPI:1952501942
Name:XYNELLIS, JASON CHARLES (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:CHARLES
Last Name:XYNELLIS
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1195 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02904-1824
Mailing Address - Country:US
Mailing Address - Phone:401-331-8555
Mailing Address - Fax:
Practice Address - Street 1:1195 N MAIN ST
Practice Address - Street 2:
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02904-1824
Practice Address - Country:US
Practice Address - Phone:401-331-8555
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPA00501363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0021338OtherMEDICARE PTAN
RIJX84601Medicaid