Provider Demographics
NPI:1457934408
Name:TRENT, JASON KONSTANTIN (MD)
Entity type:Individual
Prefix:DR
First Name:JASON
Middle Name:KONSTANTIN
Last Name:TRENT
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JASON
Other - Middle Name:KONSTATIN
Other - Last Name:TRENT
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:464 LUCE AVE
Mailing Address - Street 2:
Mailing Address - City:UKIAH
Mailing Address - State:CA
Mailing Address - Zip Code:95482-5631
Mailing Address - Country:US
Mailing Address - Phone:707-463-1578
Mailing Address - Fax:
Practice Address - Street 1:464 LUCE AVE
Practice Address - Street 2:
Practice Address - City:UKIAH
Practice Address - State:CA
Practice Address - Zip Code:95482-5631
Practice Address - Country:US
Practice Address - Phone:707-463-1578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-28
Last Update Date:2021-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC-3243207ZF0201X
HIMD-1858207ZF0201X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZF0201XAllopathic & Osteopathic PhysiciansPathologyForensic Pathology