Provider Demographics
NPI:1962724260
Name:DALE, JONATHAN ROBERT (PA-C)
Entity type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:ROBERT
Last Name:DALE
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 1:863 N MAIN STREET EXT STE 200
Mailing Address - Street 2:
Mailing Address - City:WALLINGFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06492-2434
Mailing Address - Country:US
Mailing Address - Phone:203-265-3280
Mailing Address - Fax:
Practice Address - Street 1:863 N MAIN STREET EXT STE 200
Practice Address - Street 2:
Practice Address - City:WALLINGFORD
Practice Address - State:CT
Practice Address - Zip Code:06492-2434
Practice Address - Country:US
Practice Address - Phone:203-265-3280
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-28
Last Update Date:2019-12-21
Deactivation Date:2019-01-21
Deactivation Code:
Reactivation Date:2019-03-06
Provider Licenses
StateLicense IDTaxonomies
CT4398363A00000X
NY001559-12255A2300X
PART0040342255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer