Provider Demographics
NPI:1275045791
Name:SURBATOVICH, JOSIAH JAMES (PHYSICIAN ASSISTANT)
Entity Type:Individual
Prefix:
First Name:JOSIAH
Middle Name:JAMES
Last Name:SURBATOVICH
Suffix:
Gender:M
Credentials:PHYSICIAN ASSISTANT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 CANAL LANDING BLVD STE 1
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:NY
Mailing Address - Zip Code:14626-5107
Mailing Address - Country:US
Mailing Address - Phone:585-368-4050
Mailing Address - Fax:585-723-6705
Practice Address - Street 1:170 WEST AVE
Practice Address - Street 2:
Practice Address - City:BROCKPORT
Practice Address - State:NY
Practice Address - Zip Code:14420-1227
Practice Address - Country:US
Practice Address - Phone:585-395-6052
Practice Address - Fax:585-395-6007
Is Sole Proprietor?:No
Enumeration Date:2017-10-25
Last Update Date:2018-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY021172363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical