Basic Information
| Provider Information | |||||||||
| NPI: | 1659633147 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PENG | ||||||||
| FirstName: | JASON | ||||||||
| MiddleName: | STEVEN | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 BURNET AVE | ||||||||
| Address2: | 3 SOUTH, CENTRAL CREDENTIALING | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452293019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135585281 | ||||||||
| FaxNumber: | 5135585791 | ||||||||
| Practice Location | |||||||||
| Address1: | 234 ALBERT SABIN WAY | ||||||||
| Address2: | ML 0769 | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452672827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5135585281 | ||||||||
| FaxNumber: | 5135585791 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2012 | ||||||||
| LastUpdateDate: | 04/12/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/12/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | RN.315551 | OH | N | Nursing Service Providers | Registered Nurse | 363L00000X | COA.13491-NP | OH | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7100301250 | 05 | KY | MEDICAID | 0071432 | 05 | OH | MEDICAID |