Provider Demographics
NPI:1306203195
Name:FOSBRE, JONATHAN D (NP-C)
Entity Type:Individual
Prefix:MR
First Name:JONATHAN
Middle Name:D
Last Name:FOSBRE
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5891 W EUGIE AVE
Mailing Address - Street 2:
Mailing Address - City:GLENDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85304-1252
Mailing Address - Country:US
Mailing Address - Phone:602-588-6725
Mailing Address - Fax:
Practice Address - Street 1:5891 W EUGIE AVE
Practice Address - Street 2:
Practice Address - City:GLENDALE
Practice Address - State:AZ
Practice Address - Zip Code:85304-1252
Practice Address - Country:US
Practice Address - Phone:602-588-6725
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-01-25
Last Update Date:2016-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP8420363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily