Provider Demographics
NPI:1720829435
Name:ASTAFAN, JASON MICHAEL
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:MICHAEL
Last Name:ASTAFAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 TRENT LN
Mailing Address - Street 2:
Mailing Address - City:CAMILLUS
Mailing Address - State:NY
Mailing Address - Zip Code:13031-1615
Mailing Address - Country:US
Mailing Address - Phone:315-408-6813
Mailing Address - Fax:
Practice Address - Street 1:5586 LEGIONNAIRE DR
Practice Address - Street 2:
Practice Address - City:CICERO
Practice Address - State:NY
Practice Address - Zip Code:13039-3504
Practice Address - Country:US
Practice Address - Phone:315-728-6903
Practice Address - Fax:315-204-1070
Is Sole Proprietor?:No
Enumeration Date:2024-06-05
Last Update Date:2024-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY354414363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily