Provider Demographics
NPI:1013317361
Name:MIDDLEMISS, JONATHAN (PA-C)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:
Last Name:MIDDLEMISS
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 741648
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-1648
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1220 E 3900 S STE 4A
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84124-1326
Practice Address - Country:US
Practice Address - Phone:801-261-8507
Practice Address - Fax:801-261-8511
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-23
Last Update Date:2023-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant