Provider Demographics
NPI:1114000759
Name:MABEE, JASON CHIGORO LEE
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:CHIGORO LEE
Last Name:MABEE
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 1:1022 TREVINO ROAD
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MO
Mailing Address - Zip Code:64735
Mailing Address - Country:US
Mailing Address - Phone:660-885-5058
Mailing Address - Fax:660-885-8496
Practice Address - Street 1:100 HEALTHY WAY
Practice Address - Street 2:
Practice Address - City:OLIVIA
Practice Address - State:MN
Practice Address - Zip Code:56277-1117
Practice Address - Country:US
Practice Address - Phone:320-523-1261
Practice Address - Fax:320-523-8349
Is Sole Proprietor?:No
Enumeration Date:2006-10-24
Last Update Date:2020-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1308367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO915815906Medicaid
MO915815906Medicaid