Provider Demographics
NPI:1689822652
Name:SHOMO, JONATHAN ANTHONY (PA)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ANTHONY
Last Name:SHOMO
Suffix:
Gender:M
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110A N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEWATER
Mailing Address - State:VA
Mailing Address - Zip Code:22812-1301
Mailing Address - Country:US
Mailing Address - Phone:540-515-4325
Mailing Address - Fax:540-210-1271
Practice Address - Street 1:110A N MAIN ST
Practice Address - Street 2:
Practice Address - City:BRIDGEWATER
Practice Address - State:VA
Practice Address - Zip Code:22812-1301
Practice Address - Country:US
Practice Address - Phone:540-515-4325
Practice Address - Fax:540-210-1271
Is Sole Proprietor?:Yes
Enumeration Date:2008-09-03
Last Update Date:2021-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110002842363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1689822652Medicaid
VA1689822652Medicaid