Provider Demographics
NPI:1033574165
Name:ROSER, JESSIKA L (PA-C)
Entity Type:Individual
Prefix:
First Name:JESSIKA
Middle Name:L
Last Name:ROSER
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:JESSIKA
Other - Middle Name:
Other - Last Name:MONROE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:711 S DALE MABRY HWY STE 201
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33609-4400
Mailing Address - Country:US
Mailing Address - Phone:813-548-7860
Mailing Address - Fax:813-605-6156
Practice Address - Street 1:711 S DALE MABRY HWY STE 201
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33609-4400
Practice Address - Country:US
Practice Address - Phone:813-548-7860
Practice Address - Fax:813-605-6156
Is Sole Proprietor?:No
Enumeration Date:2015-12-16
Last Update Date:2023-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
363AM0700X
FLPA9109301363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016571600Medicaid