Provider Demographics
NPI:1649386541
Name:SURRATT, JASON RAY (DPM)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:RAY
Last Name:SURRATT
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9900 SW HALL BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:TIGARD
Mailing Address - State:OR
Mailing Address - Zip Code:97223
Mailing Address - Country:US
Mailing Address - Phone:503-245-2420
Mailing Address - Fax:503-245-2445
Practice Address - Street 1:9900 SW HALL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:TIGARD
Practice Address - State:OR
Practice Address - Zip Code:97223
Practice Address - Country:US
Practice Address - Phone:503-245-2420
Practice Address - Fax:503-245-2445
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2011-09-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
ORDP00330213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR228891Medicaid
OR117802Medicare ID - Type Unspecified
OR228891Medicaid