Provider Demographics
NPI:1255394912
Name:CONLEY, JASON (PAC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:CONLEY
Suffix:
Gender:M
Credentials:PAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 910
Mailing Address - Street 2:
Mailing Address - City:MARTIN
Mailing Address - State:KY
Mailing Address - Zip Code:41649-0910
Mailing Address - Country:US
Mailing Address - Phone:606-285-0681
Mailing Address - Fax:606-285-6619
Practice Address - Street 1:11087 MAIN ST
Practice Address - Street 2:
Practice Address - City:MARTIN
Practice Address - State:KY
Practice Address - Zip Code:41649-7999
Practice Address - Country:US
Practice Address - Phone:606-285-0681
Practice Address - Fax:606-285-6619
Is Sole Proprietor?:No
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA677363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95002614Medicaid
KYP53173Medicare UPIN
KY183440Medicare ID - Type Unspecified
183438Medicare ID - Type Unspecified
183440Medicare ID - Type Unspecified
KY95002614Medicaid