Provider Demographics
NPI:1962592972
Name:DELONG, JASON E (PA-C)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:E
Last Name:DELONG
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 SUMMERTREE DR
Mailing Address - Street 2:
Mailing Address - City:NICHOLASVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40356-9714
Mailing Address - Country:US
Mailing Address - Phone:859-553-6474
Mailing Address - Fax:859-901-0015
Practice Address - Street 1:78 SUMMERTREE DR
Practice Address - Street 2:
Practice Address - City:NICHOLASVILLE
Practice Address - State:KY
Practice Address - Zip Code:40356-9714
Practice Address - Country:US
Practice Address - Phone:859-553-6474
Practice Address - Fax:833-645-2179
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2025-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYPA585363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY95004339Medicaid
KY2092375OtherWELLCARE
KYQMP000005624542OtherMOLINA
KY95004339Medicaid
KY000000324312OtherANTHEM BCBS PROVIDER ID
KYCS1914400188OtherCARESOURCE
KYP400023815Medicare PIN
KY7500Medicare PIN
200312945OtherFEDERAL TAX ID
KY95004339Medicaid
KY0796302Medicare PIN