NPIMap

Individual provider Active NPI

Jason Tyler Dumrongkulraksa

  • Physician Assistant
  • Panama City, FL
National Provider Identifier
1205115573
Registry record updated Dec 16, 2011
On this page

Key facts

NPPES NPI Registry
Primary specialty
Physician AssistantTaxonomy code 363A00000X
License
PA9106023 Issued in FL
Practice address
615 N Bonita Ave
Panama City, FL 32401-3623
Phone
(850) 747-6000
NPI assigned
Aug 4, 2011
Last updated
Dec 16, 2011By the provider in NPPES
Sex
Male
Sole proprietor
Yes

NPPES NPI Registry

Updated by the provider on Dec 16, 2011

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Physician Assistant 363A00000X PA9106023 FL Primary

Addresses

Primary practice location

615 N Bonita Ave
Panama City, FL 32401-3623

Mailing address

615 N Bonita Ave
Panama City, FL 32401-3623
Phone (850) 747-6000

Other identifiers 1

IdentifierTypeStateIssuer
PA9106023OtherFLFLORIDA BOARD OF MEDICINE

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in FL
Eligible to order & refer
  • Part B services
  • Medical equipment
  • Home health
  • Power mobility devices
  • Hospice
Green means eligible to order or refer.

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
I20130218000514 FL Practitioner - Physician Assistant 3870748064 Reassigns benefits to 5 organizations

Care Compare profile

Medicare Care Compare
Specialty
Physician Assistant
Education
Other, 2011
Medicare assignment
Accepts the Medicare-approved amount as payment in full
Group practices
Hospital Medicine Services of FL, LLCGroup PAC ID 9234596743, 513 clinicians

Practice addresses (Care Compare)

340 NW Commerce Dr
Lake City Medical Center
Lake City, FL 32055-4709
Phone (850) 719-9000

449 W 23Rd St
HCA Florida Gulf Coast Hospital
Panama City, FL 32405-4593
Phone (813) 873-6400

Hospital & facility affiliations

National Provider Directory

National Provider Directory
Medicare enrollment (NPD)
Not enrolled
HHS exclusion list flag
CMS’s directory marks this NPI as on an HHS exclusion list; no matching OIG record was found. The OIG exclusions file (LEIE) holds no record for this NPI, and the directory does not say which list the flag comes from. How exclusions are shown Confirm with the OIG exclusions search.
Credentials
Physician Assistant

Practice roles

OrganizationSpecialtyStatusNew patients
FL-I Medical Services LLC Physician Assistant CurrentSince Oct 1, 2016 Accepting new patients
FL-I Medical Services LLC Physician Assistant CurrentSince Oct 1, 2016 Accepting new patients
Blue Wave Emergency Physicians LLC Past Accepting new patients
Acsh Urgent Care of Florida, LLC Past Accepting new patients
Emerald Waters Inpatient Services LLC Past Accepting new patients

Locations

322 SW Pine Island Rd
Cape Coral, FL 33991
Phone (941) 249-6858

996 Airport Rd
Destin, FL 32541
Phone (615) 338-1250

1700 S 23rd St
Fort Pierce, FL 34950
Phone (772) 461-4000

1000 Mar Walt Dr
Ft Walton Bch, FL 32547
Phone (850) 374-9610

340 NW Commerce Dr
Lake City, FL 32055
Phone (386) 719-9000

20900 Biscayne Blvd
Miami, FL 33180
Phone (305) 682-7290

2190 Highway 85 N
Niceville, FL 32578
Phone (850) 678-4131

449 W 23rd St
Panama City, FL 32405
Phone (850) 747-7900

2901 W Swann Ave
Fl S
Tampa, FL 33609
Phone (813) 873-6400

Organizations & group practices 10

Organizations this provider is connected to: Medicare benefit reassignments (the organization bills Medicare for this provider’s services), Care Compare group memberships, National Provider Directory roles and organizations whose NPPES authorized official is this provider.

Hospital & facility affiliations 3

Hospitals and other facilities this clinician is affiliated with according to Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1312416000000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1323993600000",
    "number": "1205115573",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "615 N BONITA AVE",
            "city": "PANAMA CITY",
            "state": "FL",
            "postal_code": "324013623",
            "telephone_number": "850-747-6000"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "615 N BONITA AVE",
            "city": "PANAMA CITY",
            "state": "FL",
            "postal_code": "324013623",
            "telephone_number": "850-747-6000"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "DUMRONGKULRAKSA",
        "first_name": "JASON",
        "middle_name": "TYLER",
        "sole_proprietor": "YES",
        "sex": "M",
        "enumeration_date": "2011-08-04",
        "last_updated": "2011-12-16",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "363A00000X",
            "taxonomy_group": "",
            "desc": "Physician Assistant",
            "state": "FL",
            "license": "PA9106023",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "FLORIDA BOARD OF MEDICINE",
            "identifier": "PA9106023",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Panama City, FL

Sources for this page

Verify at the official NPI Registry.