Provider Demographics
NPI:1548263882
Name:KOTULA, JASON (PA)
Entity type:Individual
Prefix:MR
First Name:JASON
Middle Name:
Last Name:KOTULA
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3627 UNIVERSITY BLVD S STE 415
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-4299
Mailing Address - Country:US
Mailing Address - Phone:904-296-2522
Mailing Address - Fax:
Practice Address - Street 1:3627 UNIVERSITY BLVD S STE 415
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32216-4299
Practice Address - Country:US
Practice Address - Phone:904-296-2522
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2022-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001621363A00000X
NY009808363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY5482L1Medicare ID - Type Unspecified
NYQ18205Medicare UPIN