# JASON EDWARD LAKE

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- **Entity:** Individual
- **Status:** Active
- **Sole proprietor:** No

## Provider details

- **NPI number:** 1205051430
- **Gender:** Man
- **Credential:** MD

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 207X00000X | Orthopaedic Surgery Physician | 19568 | MS | — |
| 207X00000X | Orthopaedic Surgery Physician | 35. 093195 | OH | — |
| 207X00000X | Orthopaedic Surgery Physician | 42724 | AZ | — |
| 207XX0004X | Orthopaedic Foot and Ankle Surgery Physician | 42724 | AZ | Yes |

## Other

- **Enumeration date:** 04/14/2007
- **Last updated:** 03/25/2025

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 3Z5372 | HEALTHNET | AZ |