Healthcare Provider Details

I. General information

NPI: 1821529918
Provider Name (Legal Business Name): JONATHAN SUBAITANI PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/21/2017
Last Update Date: 05/07/2026
Certification Date: 05/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 S WOODDALE AVE
EAGLE ID
83616-7714
US

IV. Provider business mailing address

219 S WOODDALE AVE
EAGLE ID
83616-7714
US

V. Phone/Fax

Practice location:
  • Phone: 703-928-7266
  • Fax:
Mailing address:
  • Phone: 703-928-7266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberPA-1596
License Number StateID
# 3
Primary TaxonomyN
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number0110005599
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: