Healthcare Provider Details

I. General information

NPI: 1164411914
Provider Name (Legal Business Name): ROBERT A JELACO PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/14/2005
Last Update Date: 02/06/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4650 HARRISON BLVD
OGDEN UT
84403-4303
US

IV. Provider business mailing address

4650 HARRISON BLVD
OGDEN UT
84403-4303
US

V. Phone/Fax

Practice location:
  • Phone: 801-475-3000
  • Fax: 801-475-3001
Mailing address:
  • Phone: 801-475-3000
  • Fax: 801-475-3001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number102917-1206
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: