Basic Information
| Provider Information | |||||||||
| NPI: | 1679666572 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FEDAK | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | PA-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068108047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8602101850 | ||||||||
| FaxNumber: | 2038262139 | ||||||||
| Practice Location | |||||||||
| Address1: | 2 MAIN ST | ||||||||
| Address2: | |||||||||
| City: | DANBURY | ||||||||
| State: | CT | ||||||||
| PostalCode: | 068108047 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2038262140 | ||||||||
| FaxNumber: | 2038262139 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/02/2006 | ||||||||
| LastUpdateDate: | 03/02/2015 | ||||||||
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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 | 363AM0700X | 001470 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical |
ID Information
| ID | Type | State | Issuer | Description | 290001470CT01 | 01 | ANTHEM BCBS | OTHER | 147000 | 01 | CONNECTICARE | OTHER | 2V4615 | 01 | HEALTHNET OF THE NORTHEAS | OTHER | P3613396 | 01 | OXFORD HEALTH PLANS | OTHER |