Provider Demographics
NPI:1720428865
Name:ROSENWALD, JASON A (PA)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:A
Last Name:ROSENWALD
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 1:2790 GODWIN BLVD
Mailing Address - Street 2:SUITE 320
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23434-8151
Mailing Address - Country:US
Mailing Address - Phone:757-470-5570
Mailing Address - Fax:
Practice Address - Street 1:2790 GODWIN BLVD
Practice Address - Street 2:SUITE 320
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23434-8151
Practice Address - Country:US
Practice Address - Phone:757-470-5570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-03
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0110-004299363AS0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical