Provider Demographics
NPI:1316117930
Name:SOUTHALL, JASON R (PA-C)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:R
Last Name:SOUTHALL
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:2 STONECREST DR
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON
Mailing Address - State:WV
Mailing Address - Zip Code:25701-9391
Mailing Address - Country:US
Mailing Address - Phone:304-525-2273
Mailing Address - Fax:304-525-2165
Practice Address - Street 1:2 STONECREST DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25701-9391
Practice Address - Country:US
Practice Address - Phone:304-525-2273
Practice Address - Fax:304-525-2165
Is Sole Proprietor?:No
Enumeration Date:2008-03-11
Last Update Date:2021-04-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WV01257363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0080128Medicaid
KY7100109950Medicaid
WVP0071530OtherRR
WV1316117930Medicaid