Provider Demographics
NPI:1396770202
Name:BADILLO, JASON (PA)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:BADILLO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15225 SHADY GROVE RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20850-3254
Mailing Address - Country:US
Mailing Address - Phone:301-947-2415
Mailing Address - Fax:240-632-0164
Practice Address - Street 1:15225 SHADY GROVE RD
Practice Address - Street 2:SUITE 201
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20850-3254
Practice Address - Country:US
Practice Address - Phone:301-947-2415
Practice Address - Fax:240-632-0164
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC0002834363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDQ09444Medicare UPIN