Provider Demographics
NPI:1366400962
Name:SEYMOUR, JASON ERIC (PA-C)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:ERIC
Last Name:SEYMOUR
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:103 WINDING ROAD
Mailing Address - Street 2:DIPRETA DERMATOLOGY
Mailing Address - City:BRUNSWICK
Mailing Address - State:GA
Mailing Address - Zip Code:31525
Mailing Address - Country:US
Mailing Address - Phone:912-510-7546
Mailing Address - Fax:912-510-7550
Practice Address - Street 1:5 EXECUTIVE CIR
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:GA
Practice Address - Zip Code:31406-3345
Practice Address - Country:US
Practice Address - Phone:912-355-2400
Practice Address - Fax:912-355-5324
Is Sole Proprietor?:No
Enumeration Date:2006-05-03
Last Update Date:2017-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003481363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA100001610EMedicaid
GA01158096OtherAMERIGROUP
GA100001610FMedicaid
GA100001610FMedicaid
GAP44684Medicare UPIN
GAP00444645Medicare PIN