MEDICARE: MR. JEFFREY EVAN ISAAC PA-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363A00000X	Physician Assistant	969	CO

General Provider Information

NPI Number	:	1578566857
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. JEFFREY EVAN ISAAC PA-C

Provider Business Mailing Address
First Line	:	PO BOX 1850
Second Line	:
City	:	CRESTED BUTTE
State	:	CO
Zip	:	81224-1850
Country	:	US
Telephone Number	:	970-349-0321
Fax Number	:	970-349-2985

Provider Business Practice Location Address
First Line	:	214 SIXTH STREET
Second Line	:	SUITE 1
City	:	CRESTED BUTTE
State	:	CO
Zip	:	81224-1850
Country	:	US
Telephone Number	:	970-349-0321
Fax Number	:	970-349-2985

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	02/22/2010

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