Provider Demographics
NPI:1578946968
Name:MILBERT, JASON DEAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:DEAN
Last Name:MILBERT
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 1:71 STARKWEATHER ST
Mailing Address - Street 2:FL 1
Mailing Address - City:MANCHESTER
Mailing Address - State:CT
Mailing Address - Zip Code:06042-3213
Mailing Address - Country:US
Mailing Address - Phone:951-212-3572
Mailing Address - Fax:
Practice Address - Street 1:21576 N PARK DR
Practice Address - Street 2:
Practice Address - City:FAIRVIEW PARK
Practice Address - State:OH
Practice Address - Zip Code:44126-2324
Practice Address - Country:US
Practice Address - Phone:440-724-6363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-02
Last Update Date:2015-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT3343363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant