Provider Demographics
NPI:1285222315
Name:CROSNO, JESSE TYLER (PA)
Entity type:Individual
Prefix:
First Name:JESSE
Middle Name:TYLER
Last Name:CROSNO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 SW 84TH AVE STE 102
Mailing Address - Street 2:
Mailing Address - City:PLANTATION
Mailing Address - State:FL
Mailing Address - Zip Code:33324-2729
Mailing Address - Country:US
Mailing Address - Phone:954-349-2345
Mailing Address - Fax:954-349-7784
Practice Address - Street 1:220 SW 84TH AVE STE 102
Practice Address - Street 2:
Practice Address - City:PLANTATION
Practice Address - State:FL
Practice Address - Zip Code:33324-2729
Practice Address - Country:US
Practice Address - Phone:954-720-1530
Practice Address - Fax:954-620-5751
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-05
Last Update Date:2024-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPA9116412363A00000X, 363AM0700X, 363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical