Provider Demographics
NPI:1700404936
Name:MUSTACCHIO, JADEN (PA-C)
Entity Type:Individual
Prefix:
First Name:JADEN
Middle Name:
Last Name:MUSTACCHIO
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 1:555 N ARLINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:RENO
Mailing Address - State:NV
Mailing Address - Zip Code:89503-4723
Mailing Address - Country:US
Mailing Address - Phone:775-786-3040
Mailing Address - Fax:775-786-1887
Practice Address - Street 1:555 N ARLINGTON AVE
Practice Address - Street 2:
Practice Address - City:RENO
Practice Address - State:NV
Practice Address - Zip Code:89503-4723
Practice Address - Country:US
Practice Address - Phone:775-786-3040
Practice Address - Fax:775-788-5216
Is Sole Proprietor?:No
Enumeration Date:2020-07-14
Last Update Date:2022-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVPA2484363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
15381809OtherCAQH
NV1700404936Medicaid