Provider Demographics
NPI:1891471769
Name:MONTALBANO, JASPER GABRIEL (PA)
Entity Type:Individual
Prefix:
First Name:JASPER
Middle Name:GABRIEL
Last Name:MONTALBANO
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 1:301 WEST NORTH ST APT 282
Mailing Address - Street 2:
Mailing Address - City:WAUKESHA
Mailing Address - State:WI
Mailing Address - Zip Code:53188
Mailing Address - Country:US
Mailing Address - Phone:815-245-2562
Mailing Address - Fax:
Practice Address - Street 1:10625 W. NORTH AVE. SUITE 101B
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226
Practice Address - Country:US
Practice Address - Phone:414-877-5350
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-26
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI7450-23363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant