Provider Demographics
NPI:1720089212
Name:TIPPIE, JASON MICHAEL (PA-C)
Entity Type:Individual
Prefix:MR
First Name:JASON
Middle Name:MICHAEL
Last Name:TIPPIE
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 1:3130 N COUNTY RD 25A
Mailing Address - Street 2:SUITE 109
Mailing Address - City:TROY
Mailing Address - State:OH
Mailing Address - Zip Code:45373-1337
Mailing Address - Country:US
Mailing Address - Phone:937-440-9292
Mailing Address - Fax:937-440-4227
Practice Address - Street 1:3130 N COUNTY RD 25A
Practice Address - Street 2:SUITE 109
Practice Address - City:TROY
Practice Address - State:OH
Practice Address - Zip Code:45373-1337
Practice Address - Country:US
Practice Address - Phone:937-440-9292
Practice Address - Fax:937-440-4227
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2015-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH50001557363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0124214Medicaid
OH0124214Medicaid