Basic Information
| Provider Information | |||||||||
| NPI: | 1346435120 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANCE | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2121 E HARMONY RD | ||||||||
| Address2: | STE 330 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805283400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706244439 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2121 E HARMONY RD | ||||||||
| Address2: | STE 330 | ||||||||
| City: | FORT COLLINS | ||||||||
| State: | CO | ||||||||
| PostalCode: | 805283400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9706244439 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/13/2007 | ||||||||
| LastUpdateDate: | 12/26/2014 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 2491 | CO | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363AM0700X | 2491 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 363AS0400X | 2491 | CO | N | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Surgical |
ID Information
| ID | Type | State | Issuer | Description | 43529577 | 05 | CO | MEDICAID |