Provider Demographics
NPI:1043207400
Name:ALTLAND, JONATHAN D (PA-C)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:D
Last Name:ALTLAND
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 1:4815 LIBERTY AVE STE 439
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15224-2156
Mailing Address - Country:US
Mailing Address - Phone:412-578-3925
Mailing Address - Fax:412-605-6364
Practice Address - Street 1:4815 LIBERTY AVE STE 439
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15224-2156
Practice Address - Country:US
Practice Address - Phone:412-578-3925
Practice Address - Fax:412-605-6364
Is Sole Proprietor?:No
Enumeration Date:2005-09-30
Last Update Date:2020-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMA056429363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103209166Medicaid
PA103209166Medicaid