Provider Demographics
NPI:1902121379
Name:VASTINE, CLARENCE JASON (FNP-C)
Entity Type:Individual
Prefix:MR
First Name:CLARENCE
Middle Name:JASON
Last Name:VASTINE
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3815 E BELL RD STE 2200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85032-2139
Mailing Address - Country:US
Mailing Address - Phone:602-633-3848
Mailing Address - Fax:
Practice Address - Street 1:13555 W MCDOWELL RD STE 103
Practice Address - Street 2:
Practice Address - City:GOODYEAR
Practice Address - State:AZ
Practice Address - Zip Code:85395-2625
Practice Address - Country:US
Practice Address - Phone:623-932-1157
Practice Address - Fax:623-935-1045
Is Sole Proprietor?:No
Enumeration Date:2010-03-29
Last Update Date:2019-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP3558363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ136913OtherMEDICARE
AZ510044Medicaid