Provider Demographics
NPI:1255403861
Name:MAYBERRY, JASON (PAC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:MAYBERRY
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 1:62 W 7TH AVE STE 110
Mailing Address - Street 2:
Mailing Address - City:SPOKANE
Mailing Address - State:WA
Mailing Address - Zip Code:99204-2321
Mailing Address - Country:US
Mailing Address - Phone:509-462-6485
Mailing Address - Fax:509-462-5059
Practice Address - Street 1:62 W 7TH AVE STE 110
Practice Address - Street 2:
Practice Address - City:SPOKANE
Practice Address - State:WA
Practice Address - Zip Code:99204-2321
Practice Address - Country:US
Practice Address - Phone:509-462-6485
Practice Address - Fax:509-462-5059
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2021-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA19289363A00000X
WAPA60698165363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAPA19289OtherLICENSE
0PA192890OtherMEDICARE INDIVIDUAL PTAN
CAPA19289OtherLICENSE