Provider Demographics
NPI:1417959693
Name:BRILLHART, JON CHRISTOPHER (PA-C)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:CHRISTOPHER
Last Name:BRILLHART
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:PO BOX 7429
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:VA
Mailing Address - Zip Code:23707-0429
Mailing Address - Country:US
Mailing Address - Phone:785-767-3050
Mailing Address - Fax:
Practice Address - Street 1:2929 LONDON BLVD
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:VA
Practice Address - Zip Code:23707-3405
Practice Address - Country:US
Practice Address - Phone:757-397-1201
Practice Address - Fax:757-398-0809
Is Sole Proprietor?:No
Enumeration Date:2005-06-01
Last Update Date:2023-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110001199363AS0400X, 363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010073871Medicaid
VA004605P62Medicare ID - Type Unspecified