Provider Demographics
NPI:1104808369
Name:ANDRUS, JASON D (PA)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:D
Last Name:ANDRUS
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1450 CHAPEL ST
Mailing Address - Street 2:HOSPITAL OF SAINT RAPHAEL, DEPARTMENT OF SURGERY
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06511-4405
Mailing Address - Country:US
Mailing Address - Phone:203-789-3501
Mailing Address - Fax:
Practice Address - Street 1:1450 CHAPEL ST
Practice Address - Street 2:HOSPITAL OF SAINT RAPHAEL, DEPARTMENT OF SURGERY
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06511-4405
Practice Address - Country:US
Practice Address - Phone:203-789-3501
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-15
Last Update Date:2012-07-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001011363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
1104808369OtherNPI
CTP00461315OtherRAILROAD MEDICARE PROVIDER NUMBER
CT970002460Medicare PIN
P24657Medicare UPIN
970001179Medicare ID - Type Unspecified