Provider Demographics
NPI:1164826442
Name:SANTOS, JASON (PHYSICIAN ASSISTANT)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:SANTOS
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2100 N OCEAN BLVD APT 504
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33305-1935
Mailing Address - Country:US
Mailing Address - Phone:954-303-5383
Mailing Address - Fax:
Practice Address - Street 1:4302 ALTON RD
Practice Address - Street 2:SUITE 705
Practice Address - City:MIAMI BEACH
Practice Address - State:FL
Practice Address - Zip Code:33140-2891
Practice Address - Country:US
Practice Address - Phone:305-534-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-10-15
Last Update Date:2014-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9108213363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant