Individual
JASON P KNISELY
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
PA
Contact information
Practice address
5050 N CLINTON ST, FORT WAYNE, IN 46825-5886
(260) 484-8551
(260) 484-9603
Mailing address
5052 N CLINTON ST, FORT WAYNE, IN 46825-5822
(260) 484-8551
(260) 482-5060
Taxonomy
Speciality
Code
Description
License number
State
363A00000X
Physician Assistant
Primary
10000501A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
11477735
CAQH
IN
05
—
300006046
—
IN
01
—
970020556
RAIL ROAD MEDICARE
IN
Enumeration date
08/17/2005
Last updated
10/30/2018
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