Provider Demographics
NPI:1427142116
Name:DONOVAN, JASON M (PA-C)
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:M
Last Name:DONOVAN
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:601 ELMWOOD AVE BOX 656
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14642-0001
Mailing Address - Country:US
Mailing Address - Phone:585-275-2838
Mailing Address - Fax:585-273-1068
Practice Address - Street 1:601 ELMWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14642
Practice Address - Country:US
Practice Address - Phone:585-275-2838
Practice Address - Fax:585-273-1068
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY9398363A00000X
NY009398363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY118048FZOtherPREFERRED CARE
NYPO19009398OtherBLUE CHOICE
NYPO19009398OtherBLUE CHOICE