Provider Demographics
NPI:1396791109
Name:WELCH, JASON L (NP)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:L
Last Name:WELCH
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:630 HOLLY SPRINGS TER
Mailing Address - Street 2:
Mailing Address - City:OVIEDO
Mailing Address - State:FL
Mailing Address - Zip Code:32765-5938
Mailing Address - Country:US
Mailing Address - Phone:386-256-1444
Mailing Address - Fax:321-400-1118
Practice Address - Street 1:3951 S NOVA RD
Practice Address - Street 2:SUITE 3
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-9270
Practice Address - Country:US
Practice Address - Phone:386-256-1444
Practice Address - Fax:321-400-1118
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3391542363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL008714000Medicaid
FLU6137ZMedicare ID - Type Unspecified
Q53799Medicare UPIN