Basic Information
| Provider Information | |||||||||
| NPI: | 1366671026 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SMITH | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | G | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7365 MAIN ST | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | STRATFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066141300 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843072 | ||||||||
| FaxNumber: | 2033844619 | ||||||||
| Practice Location | |||||||||
| Address1: | 267 GRANT ST | ||||||||
| Address2: | |||||||||
| City: | BRIDGEPORT | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066102805 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2033843072 | ||||||||
| FaxNumber: | 2033844619 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2009 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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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 | 363L00000X | 004146 | CT | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 367500000X | 071219 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.