Basic Information
| Provider Information | |||||||||
| NPI: | 1932296415 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FORRO | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | GARDNER | ||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 13008 | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489013008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173646253 | ||||||||
| FaxNumber: | 5173646208 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 E MICHIGAN AVE | ||||||||
| Address2: | |||||||||
| City: | LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 489121811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173642789 | ||||||||
| FaxNumber: | 5173643943 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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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 | 367500000X | 4704242075 | MI | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
ID Information
| ID | Type | State | Issuer | Description | 4308702470 | 01 | MI | BCBS INDIVIDUAL PIN | OTHER | 4593328 | 05 | MI | MEDICAID |