Healthcare Provider Details

I. General information

NPI: 1215446158
Provider Name (Legal Business Name): JASON ROBERTO PA-C, ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/22/2017
Last Update Date: 11/03/2023
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1420 N MONROE ST
MONROE MI
48162-4211
US

IV. Provider business mailing address

1 SEAGATE STE 800
TOLEDO OH
43604-1558
US

V. Phone/Fax

Practice location:
  • Phone: 734-240-8480
  • Fax:
Mailing address:
  • Phone: 734-240-8480
  • Fax: 734-384-0469

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number5315089057
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: