Basic Information
| Provider Information | |||||||||
| NPI: | 1164982633 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | FERNANDEZ | ||||||||
| FirstName: | JASON | ||||||||
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| Credential: | CMA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17024 40TH AVE W | ||||||||
| Address2: | |||||||||
| City: | LYNNWOOD | ||||||||
| State: | WA | ||||||||
| PostalCode: | 980377014 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2064595659 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4526 FEDERAL AVE # MS 11 | ||||||||
| Address2: | |||||||||
| City: | EVERETT | ||||||||
| State: | WA | ||||||||
| PostalCode: | 982032132 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4253496200 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/21/2019 | ||||||||
| LastUpdateDate: | 08/19/2019 | ||||||||
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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 | 374700000X | 60383237 | WA | Y | Nursing Service Related Providers | Technician | 207Q00000X | CM60383237 | WA | N | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | CM60383237 | 01 | WA | WADOH | OTHER |