Provider Demographics
NPI:1528075975
Name:GREEN, JASON A (CRNA, MSN)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:A
Last Name:GREEN
Suffix:
Gender:M
Credentials:CRNA, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:311 N CLYDE MORRIS BLVD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32114-2781
Mailing Address - Country:US
Mailing Address - Phone:386-255-1266
Mailing Address - Fax:386-255-8520
Practice Address - Street 1:311 N CLYDE MORRIS BLVD
Practice Address - Street 2:SUITE 350
Practice Address - City:DAYTONA BEACH
Practice Address - State:FL
Practice Address - Zip Code:32114-2781
Practice Address - Country:US
Practice Address - Phone:386-255-1266
Practice Address - Fax:386-255-8520
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2007-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLRN3266912367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
U1275WMedicare ID - Type Unspecified