Provider Demographics
NPI:1215103387
Name:PAHL, JASON SCOTT (RN)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:SCOTT
Last Name:PAHL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2066 TIMOTHY LN
Mailing Address - Street 2:
Mailing Address - City:MOSINEE
Mailing Address - State:WI
Mailing Address - Zip Code:54455-7205
Mailing Address - Country:US
Mailing Address - Phone:715-218-1377
Mailing Address - Fax:
Practice Address - Street 1:2066 TIMOTHY LN
Practice Address - Street 2:
Practice Address - City:MOSINEE
Practice Address - State:WI
Practice Address - Zip Code:54455-7205
Practice Address - Country:US
Practice Address - Phone:715-218-1377
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-07
Last Update Date:2008-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI156811-030163W00000X, 163WH0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI35056100Medicaid