Provider Demographics
NPI:1861637274
Name:AGUSTIN, JASON KENNETH (PA-C)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:KENNETH
Last Name:AGUSTIN
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 1:136 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:SAN GABRIEL
Mailing Address - State:CA
Mailing Address - Zip Code:91775-2720
Mailing Address - Country:US
Mailing Address - Phone:562-833-0184
Mailing Address - Fax:
Practice Address - Street 1:136 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91775-2720
Practice Address - Country:US
Practice Address - Phone:562-833-0184
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-12-15
Last Update Date:2023-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA20040363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical