Healthcare Provider Details

I. General information

NPI: 1114059987
Provider Name (Legal Business Name): JACK W ROMANO PA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/09/2007
Last Update Date: 05/01/2026
Certification Date: 05/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 W PAPERMILL RUN UNIT 311
KIMBERLY WI
54136-5507
US

IV. Provider business mailing address

300 W PAPERMILL RUN UNIT 311
KIMBERLY WI
54136-5507
US

V. Phone/Fax

Practice location:
  • Phone: 206-940-0962
  • Fax:
Mailing address:
  • Phone: 206-940-0962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA10002119
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: