Provider Demographics
NPI:1508018342
Name:ZAVILLA, JARED BLAKE (PA-C)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:BLAKE
Last Name:ZAVILLA
Suffix:
Gender:M
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 13579
Mailing Address - Street 2:
Mailing Address - City:READING
Mailing Address - State:PA
Mailing Address - Zip Code:19612-3579
Mailing Address - Country:US
Mailing Address - Phone:484-628-0799
Mailing Address - Fax:484-334-7026
Practice Address - Street 1:206 E BROWN ST
Practice Address - Street 2:
Practice Address - City:EAST STROUDSBURG
Practice Address - State:PA
Practice Address - Zip Code:18301-3006
Practice Address - Country:US
Practice Address - Phone:570-422-8243
Practice Address - Fax:570-426-2637
Is Sole Proprietor?:No
Enumeration Date:2008-10-10
Last Update Date:2019-11-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMA053682363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA135850Medicare PIN