Provider Demographics
NPI:1457606618
Name:DOUGLAS, JASON (PA-C)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:DOUGLAS
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 1:23401 PRAIRIE STAR PKWY STE B-300
Mailing Address - Street 2:
Mailing Address - City:LENEXA
Mailing Address - State:KS
Mailing Address - Zip Code:66227-7268
Mailing Address - Country:US
Mailing Address - Phone:913-677-6319
Mailing Address - Fax:913-677-1450
Practice Address - Street 1:23401 PRAIRIE STAR PKWY STE B-300
Practice Address - Street 2:
Practice Address - City:LENEXA
Practice Address - State:KS
Practice Address - Zip Code:66227-7268
Practice Address - Country:US
Practice Address - Phone:913-677-6319
Practice Address - Fax:913-677-1540
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-13
Last Update Date:2024-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS1501587363A00000X
MO2012021523363A00000X
MO2019044435363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant