Provider Demographics
NPI:1326514696
Name:SHORT, JONATHON ALLAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JONATHON
Middle Name:ALLAN
Last Name:SHORT
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 1:1366 PEACHWOOD DR
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48507-5635
Mailing Address - Country:US
Mailing Address - Phone:810-265-9539
Mailing Address - Fax:
Practice Address - Street 1:46961 VAN DYKE AVE
Practice Address - Street 2:
Practice Address - City:SHELBY CHARTER TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48317
Practice Address - Country:US
Practice Address - Phone:586-991-5205
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-10-15
Last Update Date:2018-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5601008879363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical