Provider Demographics
NPI:1164411914
Name:JELACO, ROBERT A (PA-C)
Entity Type:Individual
Prefix:
First Name:ROBERT
Middle Name:A
Last Name:JELACO
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 1:4650 HARRISON BLVD
Mailing Address - Street 2:
Mailing Address - City:OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4303
Mailing Address - Country:US
Mailing Address - Phone:801-475-3000
Mailing Address - Fax:801-475-3001
Practice Address - Street 1:4650 HARRISON BLVD
Practice Address - Street 2:
Practice Address - City:OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4303
Practice Address - Country:US
Practice Address - Phone:801-475-3000
Practice Address - Fax:801-475-3001
Is Sole Proprietor?:No
Enumeration Date:2005-10-14
Last Update Date:2013-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT102917-1206363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
UTS48213Medicare UPIN