Healthcare Provider Details

I. General information

NPI: 1285222315
Provider Name (Legal Business Name): JESSE TYLER CROSNO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 09/24/2024
Certification Date: 09/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

220 SW 84TH AVE STE 102
PLANTATION FL
33324-2729
US

IV. Provider business mailing address

220 SW 84TH AVE STE 102
PLANTATION FL
33324-2729
US

V. Phone/Fax

Practice location:
  • Phone: 954-720-1530
  • Fax: 954-620-5751
Mailing address:
  • Phone: 954-349-2345
  • Fax: 954-349-7784

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA9116412
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License NumberPA9116412
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA9116412
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: