Basic Information
| Provider Information | |||||||||
| NPI: | 1821329715 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WASSON | ||||||||
| FirstName: | JACOB | ||||||||
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| Credential: | P.A.-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 410 CHURCH ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126253222 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 410 CHURCH ST SE | ||||||||
| Address2: | |||||||||
| City: | MINNEAPOLIS | ||||||||
| State: | MN | ||||||||
| PostalCode: | 554550222 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6126253222 | ||||||||
| FaxNumber: | 6126251434 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2010 | ||||||||
| LastUpdateDate: | 01/14/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/14/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | 1368 (TEMPORARY) | MN | Y | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant |
No ID Information.