Provider Demographics
NPI:1285156703
Name:RUST, JASON MICHAEL (APRN)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:MICHAEL
Last Name:RUST
Suffix:
Gender:M
Credentials:APRN
Other - Prefix:MR
Other - First Name:JASON
Other - Middle Name:MICHAEL
Other - Last Name:RUST
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:APRN
Mailing Address - Street 1:2605 KENTUCKY AVE STE 402
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-3803
Mailing Address - Country:US
Mailing Address - Phone:270-443-6472
Mailing Address - Fax:270-421-6494
Practice Address - Street 1:2605 KENTUCKY AVE STE 402
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-3803
Practice Address - Country:US
Practice Address - Phone:270-443-6472
Practice Address - Fax:270-421-6494
Is Sole Proprietor?:No
Enumeration Date:2017-07-17
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3011416363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily