Provider Demographics
NPI:1215446158
Name:ROBERTO, JASON (PA-C, ATC)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:
Last Name:ROBERTO
Suffix:
Gender:M
Credentials:PA-C, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 SEAGATE STE 800
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43604-1558
Mailing Address - Country:US
Mailing Address - Phone:734-240-8480
Mailing Address - Fax:734-384-0469
Practice Address - Street 1:1420 N MONROE ST
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-4211
Practice Address - Country:US
Practice Address - Phone:734-240-8480
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-22
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5315089057363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1215446158Medicaid