Basic Information
| Provider Information | |||||||||
| NPI: | 1912938234 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | VANCE | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7586 CATCHFLY DR | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373631725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309665454 | ||||||||
| FaxNumber: | 5308726653 | ||||||||
| Practice Location | |||||||||
| Address1: | 7586 CATCHFLY DR | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373631725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5309665454 | ||||||||
| FaxNumber: | 5308726653 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/05/2006 | ||||||||
| LastUpdateDate: | 07/14/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | A60594 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | ZZZ01920Z | 01 | CA | BLUE SHIELD | OTHER |