Healthcare Provider Details

I. General information

NPI: 1508018342
Provider Name (Legal Business Name): JARED BLAKE ZAVILLA PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2008
Last Update Date: 11/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 E BROWN ST
EAST STROUDSBURG PA
18301-3006
US

IV. Provider business mailing address

PO BOX 13579
READING PA
19612-3579
US

V. Phone/Fax

Practice location:
  • Phone: 570-422-8243
  • Fax: 570-426-2637
Mailing address:
  • Phone: 484-628-0799
  • Fax: 484-334-7026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA053682
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: