Provider Demographics
NPI:1740844455
Name:ABRAHAM, JASON SCOTT
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:SCOTT
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7955 SPYGLASS HILL RD
Mailing Address - Street 2:STE A
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32940-8249
Mailing Address - Country:US
Mailing Address - Phone:321-751-3389
Mailing Address - Fax:321-242-2545
Practice Address - Street 1:3030 HARDEN BLVD
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33803-7952
Practice Address - Country:US
Practice Address - Phone:863-687-1250
Practice Address - Fax:863-687-1258
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-29
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9112718363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL111039100Medicaid