Provider Demographics
NPI:1063452266
Name:BEISER, JONATHAN M (PA-C)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:M
Last Name:BEISER
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 1:10506A MONTGOMERY RD # 300
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:OH
Mailing Address - Zip Code:45242-4402
Mailing Address - Country:US
Mailing Address - Phone:513-865-5120
Mailing Address - Fax:513-865-9875
Practice Address - Street 1:10506A MONTGOMERY RD # 300
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:OH
Practice Address - Zip Code:45242-4402
Practice Address - Country:US
Practice Address - Phone:513-865-5120
Practice Address - Fax:513-865-9875
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-07
Last Update Date:2023-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPA13591363A00000X
OH50.000812363A00000X
OH50.000812RX363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
ND0132950Medicaid